- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.94 / $1,196.28 / $1,470.88
| Professional | | $1,166.94 | $1,196.28 | $1,470.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.40 / $1,650.40 / $1,650.40
| Facility | | $1,650.40 | $1,650.40 | $1,650.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,450.00 / $2,940.00 / $4,733.00
| Professional | | $2,450.00 | $2,940.00 | $4,733.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,299.25 / $2,033.68 / $2,987.01
| Professional | | $1,299.25 | $2,033.68 | $2,987.01 |
- 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
- $979.00 / $2,049.60 / $3,698.46
| Professional | | $979.00 | $2,049.60 | $3,698.46 |