- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.50 / $2,015.00 / $10,448.79
| Professional | | $1,137.50 | $2,015.00 | $10,448.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,719.84 / $2,719.84 / $2,719.84
| Facility | | $2,719.84 | $2,719.84 | $2,719.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.59 / $2,334.48 / $3,651.36
| Professional | | $1,867.59 | $2,334.48 | $3,651.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,719.84 / $2,719.84 / $2,719.84
| Facility | | $2,719.84 | $2,719.84 | $2,719.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.00 / $1,867.59 / $3,651.36
| Professional | | $640.00 | $1,867.59 | $3,651.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.80 / $975.00 / $3,754.40
| Professional | | $709.80 | $975.00 | $3,754.40 |