- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.85 / $2,759.57 / $3,449.47
| Professional | | $2,398.85 | $2,759.57 | $3,449.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,735.96 / $2,692.46 / $3,060.32
| Facility | | $1,735.96 | $2,692.46 | $3,060.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,579.00 / $8,041.00 / $8,942.37
| Professional | | $1,579.00 | $8,041.00 | $8,942.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,502.54 / $1,502.54 / $2,528.00
| Facility | | $1,502.54 | $1,502.54 | $2,528.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,502.54 / $1,978.00 / $2,581.05
| Professional | | $1,502.54 | $1,978.00 | $2,581.05 |