- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.35 / $1,309.71 / $1,748.10
| Professional | | $1,040.35 | $1,309.71 | $1,748.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,752.00 / $2,752.00 / $2,752.00
| Facility | | $2,752.00 | $2,752.00 | $2,752.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,965.00 / $2,604.00 / $3,940.00
| Professional | | $1,965.00 | $2,604.00 | $3,940.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,725.64 / $2,312.61 / $3,813.81
| Professional | | $1,725.64 | $2,312.61 | $3,813.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,742.69 / $2,815.37 / $4,884.08
| Professional | | $1,742.69 | $2,815.37 | $4,884.08 |