- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $851.14
| Professional | | $707.95 | $707.95 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $12,589.25 / $27,542.29
| Facility | | $5,623.41 | $12,589.25 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Professional | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,023.29 / $1,122.02
| Professional | | $912.01 | $1,023.29 | $1,122.02 |