- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.50 / $1,721.55 / $2,099.61
| Professional | | $1,588.50 | $1,721.55 | $2,099.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $989.43 / $989.43 / $989.43
| Facility | | $989.43 | $989.43 | $989.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.17 / $2,305.17 / $4,171.42
| Professional | | $1,601.17 | $2,305.17 | $4,171.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.86 / $2,664.53 / $5,064.25
| Professional | | $1,877.86 | $2,664.53 | $5,064.25 |