- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.17 / $1,422.66 / $1,684.64
| Professional | | $1,356.17 | $1,422.66 | $1,684.64 |
- 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
- $2,738.00 / $3,286.00 / $4,970.00
| Professional | | $2,738.00 | $3,286.00 | $4,970.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,838.44 / $2,712.34 / $3,943.92
| Professional | | $1,838.44 | $2,712.34 | $3,943.92 |
- 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
- $1,591.54 / $2,722.10 / $4,455.08
| Professional | | $1,591.54 | $2,722.10 | $4,455.08 |