- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,134.44 / $2,134.44 / $2,557.30
| Professional | | $2,134.44 | $2,134.44 | $2,557.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $927.57 / $1,386.12 / $1,850.27
| Facility | | $927.57 | $1,386.12 | $1,850.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.04 / $1,383.04 / $1,383.04
| Professional | | $1,383.04 | $1,383.04 | $1,383.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $778.59 / $1,076.69 / $1,251.56
| Facility | | $778.59 | $1,076.69 | $1,251.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $927.57 / $1,386.12 / $1,850.27
| Facility | | $927.57 | $1,386.12 | $1,850.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.04 / $1,383.04 / $1,383.04
| Professional | | $1,383.04 | $1,383.04 | $1,383.04 |