- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,372.52 / $6,523.00 / $6,523.00
| Professional | | $1,372.52 | $6,523.00 | $6,523.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,947.56 / $1,947.56 / $1,947.56
| Facility | | $1,947.56 | $1,947.56 | $1,947.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.43 / $1,947.56 / $1,947.56
| Professional | | $1,388.43 | $1,947.56 | $1,947.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,947.56 / $2,185.30 / $2,277.00
| Facility | | $1,947.56 | $2,185.30 | $2,277.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.30 / $1,679.21 / $2,564.80
| Professional | | $1,185.30 | $1,679.21 | $2,564.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,714.62 / $2,151.67 / $3,426.19
| Professional | | $1,714.62 | $2,151.67 | $3,426.19 |