- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.43 / $2,675.43 / $3,344.29
| Professional | | $2,675.43 | $2,675.43 | $3,344.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,984.27 / $2,524.88 / $5,204.25
| Facility | | $1,984.27 | $2,524.88 | $5,204.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,222.31 / $2,553.50 / $8,781.00
| Professional | | $2,222.31 | $2,553.50 | $8,781.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,504.30 / $1,949.57 / $2,318.00
| Facility | | $1,504.30 | $1,949.57 | $2,318.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.19 / $2,222.31 / $2,553.50
| Professional | | $1,350.19 | $2,222.31 | $2,553.50 |