- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,228.50 / $1,298.70 / $1,439.10
| Professional | | $1,228.50 | $1,298.70 | $1,439.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,860.34 / $2,067.04 / $2,398.50
| Facility | | $1,860.34 | $2,067.04 | $2,398.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,325.38 / $2,325.38 / $2,325.38
| Professional | | $2,325.38 | $2,325.38 | $2,325.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,189.39 / $5,189.39 / $5,189.39
| Facility | | $5,189.39 | $5,189.39 | $5,189.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $1,053.00 / $2,531.23
| Professional | | $737.10 | $1,053.00 | $2,531.23 |