- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.37 / $981.37 / $981.37
| Professional | | $981.37 | $981.37 | $981.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,542.49 / $5,374.73 / $9,424.12
| Facility | | $3,542.49 | $5,374.73 | $9,424.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,523.00 / $4,637.00 / $7,545.39
| Facility | | $2,523.00 | $4,637.00 | $7,545.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,010.00 / $5,010.00 / $5,010.00
| Professional | | $5,010.00 | $5,010.00 | $5,010.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,296.00 / $3,500.00 / $6,361.00
| Facility | | $2,296.00 | $3,500.00 | $6,361.00 |