- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.37 / $1,114.70 / $6,072.86
| Professional | | $1,013.37 | $1,114.70 | $6,072.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.94 / $1,406.19 / $1,829.70
| Facility | | $1,216.94 | $1,406.19 | $1,829.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.08 / $1,518.81 / $2,115.28
| Professional | | $1,072.08 | $1,518.81 | $2,115.28 |
- 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
- $1,691.04 / $1,886.15 / $2,178.83
| Professional | | $1,691.04 | $1,886.15 | $2,178.83 |