- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.72 / $1,321.28 / $1,667.09
| Professional | | $1,214.72 | $1,321.28 | $1,667.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $829.01 / $829.01 / $829.01
| Facility | | $829.01 | $829.01 | $829.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.71 / $1,805.19 / $3,183.88
| Professional | | $1,255.71 | $1,805.19 | $3,183.88 |
- 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
- $1,458.46 / $2,242.09 / $3,943.30
| Professional | | $1,458.46 | $2,242.09 | $3,943.30 |