- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.53 / $1,493.53 / $1,866.92
| Professional | | $1,493.53 | $1,493.53 | $1,866.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $905.16 / $1,523.37 / $1,929.70
| Facility | | $905.16 | $1,523.37 | $1,929.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.00 / $3,225.29 / $3,225.29
| Professional | | $1,311.00 | $3,225.29 | $3,225.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.00 / $1,320.00 / $1,320.00
| Facility | | $1,320.00 | $1,320.00 | $1,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,236.00 / $1,320.00 / $1,398.96
| Professional | | $1,236.00 | $1,320.00 | $1,398.96 |