- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.62 / $1,853.62 / $2,317.03
| Professional | | $1,853.62 | $1,853.62 | $2,317.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,759.00 / $1,759.00 / $4,765.00
| Facility | | $1,759.00 | $1,759.00 | $4,765.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.82 / $1,674.69 / $7,567.11
| Professional | | $1,546.82 | $1,674.69 | $7,567.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $921.41 / $1,157.29 / $1,759.00
| Facility | | $921.41 | $1,157.29 | $1,759.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.42 / $1,647.34 / $1,866.57
| Professional | | $920.42 | $1,647.34 | $1,866.57 |