- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.92 / $1,019.30 / $1,341.43
| Professional | | $937.92 | $1,019.30 | $1,341.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $732.14 / $732.14 / $732.14
| Facility | | $732.14 | $732.14 | $732.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.74 / $1,436.84 / $2,526.35
| Professional | | $1,030.74 | $1,436.84 | $2,526.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,530.00
| Facility | | $2,000.00 | $2,000.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.25 / $1,712.73 / $3,199.21
| Professional | | $1,183.25 | $1,712.73 | $3,199.21 |