- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,464.42 / $1,479.71 / $1,859.46
| Professional | | $1,464.42 | $1,479.71 | $1,859.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,116.00 / $6,116.00 / $6,116.00
| Facility | | $6,116.00 | $6,116.00 | $6,116.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.00 / $3,382.00 / $5,117.00
| Professional | | $2,818.00 | $3,382.00 | $5,117.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,023.64 / $2,959.43 / $4,059.47
| Professional | | $2,023.64 | $2,959.43 | $4,059.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.01 / $2,691.64 / $4,741.08
| Professional | | $1,408.01 | $2,691.64 | $4,741.08 |