- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,584.27 / $2,584.27 / $3,230.34
| Professional | | $2,584.27 | $2,584.27 | $3,230.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,153.09 / $2,675.69 / $2,767.34
| Facility | | $2,153.09 | $2,675.69 | $2,767.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.00 / $4,092.23 / $14,660.15
| Professional | | $2,122.00 | $4,092.23 | $14,660.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,790.59 / $2,306.00 / $2,767.34
| Facility | | $1,790.59 | $2,306.00 | $2,767.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.46 / $2,352.13 / $3,244.86
| Professional | | $1,409.46 | $2,352.13 | $3,244.86 |