- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,579.83 / $1,579.83 / $1,579.83
| Professional | | $1,579.83 | $1,579.83 | $1,579.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $566.69 / $1,200.61 / $2,515.14
| Facility | | $566.69 | $1,200.61 | $2,515.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.89 / $1,177.75 / $1,501.63
| Professional | | $1,046.89 | $1,177.75 | $1,501.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,249.89 / $2,032.73 / $3,207.25
| Facility | | $1,249.89 | $2,032.73 | $3,207.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.73 / $756.19 / $1,304.21
| Professional | | $75.73 | $756.19 | $1,304.21 |