- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.75 / $1,116.43 / $1,406.22
| Professional | | $1,108.75 | $1,116.43 | $1,406.22 |
- 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
- $2,131.00 / $2,557.00 / $3,869.00
| Professional | | $2,131.00 | $2,557.00 | $3,869.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.75 / $1,897.93 / $3,073.21
| Professional | | $1,147.75 | $1,897.93 | $3,073.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.79 / $1,926.61 / $3,476.52
| Professional | | $1,016.79 | $1,926.61 | $3,476.52 |