- 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
- $1,420.01 / $1,887.16 / $3,658.83
| Facility | | $1,420.01 | $1,887.16 | $3,658.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,662.00 / $5,352.35 / $5,352.35
| Professional | | $1,662.00 | $5,352.35 | $5,352.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.45 / $1,040.45 / $1,662.00
| Facility | | $1,040.45 | $1,040.45 | $1,662.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.45 / $1,664.00 / $1,805.83
| Professional | | $1,040.45 | $1,664.00 | $1,805.83 |