- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.51 / $5,104.82 / $5,104.82
| Professional | | $1,390.51 | $5,104.82 | $5,104.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,568.16 / $5,530.12 / $7,439.78
| Facility | | $4,568.16 | $5,530.12 | $7,439.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.57 / $1,709.00 / $2,190.94
| Professional | | $1,247.57 | $1,709.00 | $2,190.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,138.00 / $6,138.00 / $6,138.00
| Facility | | $6,138.00 | $6,138.00 | $6,138.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.21 / $1,298.83 / $2,272.94
| Professional | | $1,050.21 | $1,298.83 | $2,272.94 |