- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.03 / $1,681.03 / $2,101.29
| Professional | | $1,681.03 | $1,681.03 | $2,101.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,448.50 / $26,542.00 / $26,542.00
| Facility | | $5,448.50 | $26,542.00 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,110.00 / $4,110.00 / $4,110.00
| Professional | | $4,110.00 | $4,110.00 | $4,110.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $872.14 / $1,221.47 / $1,710.37
| Facility | | $872.14 | $1,221.47 | $1,710.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.00 / $1,105.00 / $1,105.00
| Professional | | $1,105.00 | $1,105.00 | $1,105.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $872.14 / $1,221.47 / $1,710.37
| Facility | | $872.14 | $1,221.47 | $1,710.37 |