- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,584.89 / $2,570.40
| Professional | | $1,380.38 | $1,584.89 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,090.30
| Facility | | $2,398.83 | $2,398.83 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,630.27
| Professional | | $1,995.26 | $1,995.26 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,000.00 / $1,995.26
| Facility | | $398.11 | $1,000.00 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,318.26 / $2,041.74
| Professional | | $1,202.26 | $1,318.26 | $2,041.74 |