- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.51 / $7,032.61 / $7,032.61
| Professional | | $1,604.51 | $7,032.61 | $7,032.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,411.40 / $1,629.40 / $2,105.01
| Facility | | $1,411.40 | $1,629.40 | $2,105.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.58 / $1,758.96 / $2,449.17
| Professional | | $1,241.58 | $1,758.96 | $2,449.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,800.00 / $5,800.00 / $5,800.00
| Facility | | $5,800.00 | $5,800.00 | $5,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,901.82 / $2,184.87 / $2,523.90
| Professional | | $1,901.82 | $2,184.87 | $2,523.90 |