- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,656.00 / $1,970.84 / $9,411.79
| Professional | | $1,656.00 | $1,970.84 | $9,411.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.62 / $2,906.62 / $2,906.62
| Facility | | $2,906.62 | $2,906.62 | $2,906.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,542.10 / $2,906.62 / $3,136.40
| Professional | | $1,542.10 | $2,906.62 | $3,136.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,423.78 / $1,957.70 / $2,906.62
| Facility | | $1,423.78 | $1,957.70 | $2,906.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.40 / $2,906.62 / $3,791.90
| Professional | | $1,752.40 | $2,906.62 | $3,791.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,498.04 / $3,029.54 / $3,401.59
| Professional | | $2,498.04 | $3,029.54 | $3,401.59 |