- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.83 / $1,269.40 / $1,563.75
| Professional | | $1,171.83 | $1,269.40 | $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 / $1,698.12 / $3,031.72
| Professional | | $1,188.16 | $1,698.12 | $3,031.72 |
- 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 / $2,081.21 / $3,768.96
| Professional | | $1,393.98 | $2,081.21 | $3,768.96 |