- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.92 / $1,189.92 / $1,487.40
| Professional | | $1,189.92 | $1,189.92 | $1,487.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.98 / $2,968.44 / $2,968.44
| Facility | | $1,181.98 | $2,968.44 | $2,968.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,357.89 / $4,357.89 / $4,357.89
| Professional | | $4,357.89 | $4,357.89 | $4,357.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $583.46 / $961.55 / $1,549.00
| Facility | | $583.46 | $961.55 | $1,549.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.07 / $1,056.47 / $1,769.00
| Professional | | $640.07 | $1,056.47 | $1,769.00 |