- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.11 / $1,057.67 / $1,334.80
| Professional | | $1,055.11 | $1,057.67 | $1,334.80 |
- 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
- $2,020.00 / $2,424.00 / $3,667.00
| Professional | | $2,020.00 | $2,424.00 | $3,667.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.58 / $1,971.88 / $2,922.86
| Professional | | $1,314.58 | $1,971.88 | $2,922.86 |
- 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
- $1,080.03 / $2,093.07 / $3,298.11
| Professional | | $1,080.03 | $2,093.07 | $3,298.11 |