- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.58 / $1,246.25 / $1,584.58
| Professional | | $1,231.58 | $1,246.25 | $1,584.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,006.39 / $5,006.39 / $5,006.39
| Facility | | $5,006.39 | $5,006.39 | $5,006.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,343.00 / $2,812.00 / $4,254.00
| Professional | | $2,343.00 | $2,812.00 | $4,254.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.74 / $2,431.11 / $3,418.75
| Professional | | $1,620.74 | $2,431.11 | $3,418.75 |
- 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
- $1,416.36 / $2,511.60 / $4,265.30
| Professional | | $1,416.36 | $2,511.60 | $4,265.30 |