- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.35 / $1,468.27 / $1,858.19
| Professional | | $1,434.35 | $1,468.27 | $1,858.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.60 / $1,373.60 / $1,373.60
| Facility | | $1,373.60 | $1,373.60 | $1,373.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,762.00 / $3,314.00 / $5,015.00
| Professional | | $2,762.00 | $3,314.00 | $5,015.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.91 / $2,863.36 / $4,006.33
| Professional | | $1,908.91 | $2,863.36 | $4,006.33 |
- 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
- $1,528.63 / $2,840.44 / $4,415.18
| Professional | | $1,528.63 | $2,840.44 | $4,415.18 |