- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.27 / $1,577.16 / $1,998.41
| Professional | | $1,547.27 | $1,577.16 | $1,998.41 |
- 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
- $2,975.00 / $3,570.00 / $5,400.00
| Professional | | $2,975.00 | $3,570.00 | $5,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.66 / $3,074.49 / $4,317.75
| Professional | | $2,049.66 | $3,074.49 | $4,317.75 |
- 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
- $1,582.33 / $3,049.40 / $4,847.68
| Professional | | $1,582.33 | $3,049.40 | $4,847.68 |