- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.00 / $3,472.34 / $10,484.70
| Professional | | $2,137.00 | $3,472.34 | $10,484.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,358.81 / $3,358.81 / $3,358.81
| Facility | | $3,358.81 | $3,358.81 | $3,358.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,063.02 / $3,358.81 / $3,613.64
| Professional | | $2,063.02 | $3,358.81 | $3,613.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,653.90 / $3,510.00 / $3,778.56
| Facility | | $1,653.90 | $3,510.00 | $3,778.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,015.08 / $3,022.93 / $4,360.30
| Professional | | $2,015.08 | $3,022.93 | $4,360.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,837.85 / $3,510.00 / $5,854.31
| Professional | | $2,837.85 | $3,510.00 | $5,854.31 |