- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.72 / $1,075.64 / $1,358.44
| Professional | | $1,072.72 | $1,075.64 | $1,358.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.20 / $2,767.20 / $2,767.20
| Facility | | $2,767.20 | $2,767.20 | $2,767.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.00 / $2,470.00 / $3,736.00
| Professional | | $2,058.00 | $2,470.00 | $3,736.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.76 / $2,151.28 / $2,972.84
| Professional | | $1,461.76 | $2,151.28 | $2,972.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.58 / $2,145.31 / $3,334.68
| Professional | | $946.58 | $2,145.31 | $3,334.68 |