- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.83 / $1,334.81 / $1,563.75
| Professional | | $1,194.83 | $1,334.81 | $1,563.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $738.87 / $738.87 / $738.87
| Facility | | $738.87 | $738.87 | $738.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.16 / $1,719.25 / $3,039.77
| Professional | | $1,188.16 | $1,719.25 | $3,039.77 |
- 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
- $1,393.98 / $2,156.25 / $3,768.96
| Professional | | $1,393.98 | $2,156.25 | $3,768.96 |