- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.26 / $1,854.26 / $2,317.82
| Professional | | $1,854.26 | $1,854.26 | $2,317.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.31 / $1,760.78 / $3,658.83
| Facility | | $1,500.31 | $1,760.78 | $3,658.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,662.00 / $1,805.00 / $5,352.35
| Professional | | $1,662.00 | $1,805.00 | $5,352.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.45 / $1,348.42 / $1,662.00
| Facility | | $1,040.45 | $1,348.42 | $1,662.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.37 / $1,664.00 / $2,020.84
| Professional | | $940.37 | $1,664.00 | $2,020.84 |