- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.21 / $1,059.21 / $1,059.21
| Professional | | $1,059.21 | $1,059.21 | $1,059.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,565.44 / $2,565.44 / $2,565.44
| Facility | | $2,565.44 | $2,565.44 | $2,565.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,059.21 / $1,059.21 / $1,059.21
| Facility | | $1,059.21 | $1,059.21 | $1,059.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $722.28 / $919.04 / $970.46
| Facility | | $722.28 | $919.04 | $970.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,565.44 / $2,565.44 / $2,565.44
| Facility | | $2,565.44 | $2,565.44 | $2,565.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.87 / $3,247.95 / $3,950.94
| Facility | | $2,592.87 | $3,247.95 | $3,950.94 |