- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.36 / $1,085.99 / $1,454.45
| Professional | | $728.36 | $1,085.99 | $1,454.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.64 / $2,089.64 / $2,089.64
| Professional | | $2,089.64 | $2,089.64 | $2,089.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $1,916.91
| Facility | | $1,460.50 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.43 / $1,460.50 / $1,916.91
| Professional | | $1,241.43 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $1,916.91
| Facility | | $1,460.50 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $1,916.91
| Professional | | $1,460.50 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.12 / $1,389.81 / $2,147.80
| Professional | | $859.12 | $1,389.81 | $2,147.80 |