- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.04 / $2,511.04 / $3,138.81
| Professional | | $2,511.04 | $2,511.04 | $3,138.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,555.00 / $1,555.00 / $5,854.00
| Facility | | $1,555.00 | $1,555.00 | $5,854.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.00 / $1,635.51 / $7,745.61
| Professional | | $1,457.00 | $1,635.51 | $7,745.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.66 / $1,555.00 / $1,901.16
| Facility | | $1,513.66 | $1,555.00 | $1,901.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.37 / $1,635.51 / $2,578.30
| Professional | | $918.37 | $1,635.51 | $2,578.30 |