- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.33 / $1,635.33 / $2,044.16
| Professional | | $1,635.33 | $1,635.33 | $2,044.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,640.95 / $5,640.95 / $5,640.95
| Facility | | $5,640.95 | $5,640.95 | $5,640.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.00 / $6,228.00 / $6,228.00
| Professional | | $1,067.00 | $6,228.00 | $6,228.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $837.14 / $837.14 / $1,084.93
| Facility | | $837.14 | $837.14 | $1,084.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.14 / $1,084.93 / $1,522.05
| Professional | | $837.14 | $1,084.93 | $1,522.05 |