- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.65 / $2,480.65 / $3,100.82
| Professional | | $2,480.65 | $2,480.65 | $3,100.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,932.00 / $2,464.84 / $4,634.55
| Facility | | $1,932.00 | $2,464.84 | $4,634.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,727.00 / $2,971.64 / $8,711.23
| Professional | | $1,727.00 | $2,971.64 | $8,711.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,347.75 / $2,073.51 / $2,464.84
| Facility | | $1,347.75 | $2,073.51 | $2,464.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,727.00 / $2,113.44 / $2,971.64
| Professional | | $1,727.00 | $2,113.44 | $2,971.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $1,965.90 / $2,770.10
| Professional | | $7.00 | $1,965.90 | $2,770.10 |