- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.16 / $2,939.92 / $11,197.70
| Professional | | $1,736.16 | $2,939.92 | $11,197.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,792.00 / $2,792.00 / $2,792.00
| Facility | | $2,792.00 | $2,792.00 | $2,792.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.66 / $2,792.00 / $3,490.84
| Professional | | $1,305.66 | $2,792.00 | $3,490.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,313.51 / $1,671.74 / $3,116.96
| Facility | | $1,313.51 | $1,671.74 | $3,116.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,754.29 / $2,792.00 / $3,959.01
| Professional | | $1,754.29 | $2,792.00 | $3,959.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,119.04 / $3,237.35 / $3,663.99
| Professional | | $2,119.04 | $3,237.35 | $3,663.99 |