- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,644.68 / $2,055.85 / $3,442.90
| Professional | | $1,644.68 | $2,055.85 | $3,442.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,851.75 / $13,851.75 / $13,851.75
| Facility | | $13,851.75 | $13,851.75 | $13,851.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.00 / $5,691.35 / $5,691.35
| Professional | | $1,214.00 | $5,691.35 | $5,691.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $883.85 / $1,214.00 / $1,731.49
| Facility | | $883.85 | $1,214.00 | $1,731.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.00 / $1,453.29 / $1,731.49
| Professional | | $1,093.00 | $1,453.29 | $1,731.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.00 / $1,035.80 / $1,996.80
| Professional | | $6.00 | $1,035.80 | $1,996.80 |