- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.88 / $1,399.88 / $1,749.84
| Professional | | $1,399.88 | $1,399.88 | $1,749.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.38 / $1,356.79 / $27,883.60
| Facility | | $1,007.38 | $1,356.79 | $27,883.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,787.59 / $4,317.02 / $4,317.02
| Professional | | $2,787.59 | $4,317.02 | $4,317.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,251.89 / $23,593.81 / $30,028.49
| Facility | | $1,251.89 | $23,593.81 | $30,028.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.38 / $1,356.79 / $2,787.59
| Professional | | $1,007.38 | $1,356.79 | $2,787.59 |