- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,230.27 / $1,288.25
| Professional | | $1,174.90 | $1,230.27 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,621.81 / $3,311.31
| Facility | | $1,318.26 | $1,621.81 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Professional | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,621.81
| Facility | | $1,258.93 | $1,258.93 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $1,230.27 / $1,288.25
| Professional | | $46.77 | $1,230.27 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,621.81 / $3,311.31
| Facility | | $1,318.26 | $1,621.81 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |