- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.72 / $1,288.66 / $1,624.37
| Professional | | $1,275.72 | $1,288.66 | $1,624.37 |
- 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
- $2,444.00 / $2,933.00 / $4,438.00
| Professional | | $2,444.00 | $2,933.00 | $4,438.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.87 / $2,375.80 / $3,536.01
| Professional | | $1,583.87 | $2,375.80 | $3,536.01 |
- 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
- $1,814.47 / $2,579.25 / $4,270.47
| Professional | | $1,814.47 | $2,579.25 | $4,270.47 |