- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,613.67 / $1,613.67 / $7,657.53
| Professional | | $1,613.67 | $1,613.67 | $7,657.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.64 / $2,217.64 / $2,217.64
| Facility | | $2,217.64 | $2,217.64 | $2,217.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,884.99 / $2,217.64 / $3,059.25
| Professional | | $1,884.99 | $2,217.64 | $3,059.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.69 / $1,324.07 / $2,017.09
| Professional | | $907.69 | $1,324.07 | $2,017.09 |