- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.89 / $1,603.89 / $7,034.45
| Professional | | $1,603.89 | $1,603.89 | $7,034.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,772.06 / $2,111.63
| Facility | | $1,772.06 | $1,772.06 | $2,111.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.25 / $1,772.06 / $2,831.25
| Professional | | $1,506.25 | $1,772.06 | $2,831.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.50 / $1,095.27 / $1,925.86
| Facility | | $111.50 | $1,095.27 | $1,925.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.19 / $1,216.33 / $2,004.86
| Professional | | $902.19 | $1,216.33 | $2,004.86 |