- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.23 / $1,032.58 / $1,290.72
| Professional | | $1,008.23 | $1,032.58 | $1,290.72 |
- 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
- $1,950.00 / $2,340.00 / $3,540.00
| Professional | | $1,950.00 | $2,340.00 | $3,540.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.71 / $2,063.52 / $2,802.21
| Professional | | $1,398.71 | $2,063.52 | $2,802.21 |
- 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
- $1,407.40 / $2,065.21 / $3,469.70
| Professional | | $1,407.40 | $2,065.21 | $3,469.70 |