- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.56 / $1,067.74 / $1,347.47
| Professional | | $1,063.56 | $1,067.74 | $1,347.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.80 / $2,428.80 / $2,428.80
| Facility | | $2,428.80 | $2,428.80 | $2,428.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.00 / $2,430.00 / $3,676.00
| Professional | | $2,025.00 | $2,430.00 | $3,676.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,438.90 / $2,135.48 / $2,929.09
| Professional | | $1,438.90 | $2,135.48 | $2,929.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.73 / $2,116.75 / $3,745.30
| Professional | | $1,364.73 | $2,116.75 | $3,745.30 |