- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.05 / $1,179.50 / $1,531.14
| Professional | | $1,086.05 | $1,179.50 | $1,531.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $815.53 / $815.53 / $815.53
| Facility | | $815.53 | $815.53 | $815.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.61 / $1,632.34 / $2,884.06
| Professional | | $1,175.61 | $1,632.34 | $2,884.06 |
- 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
- $1,360.29 / $1,999.14 / $3,724.38
| Professional | | $1,360.29 | $1,999.14 | $3,724.38 |