- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.34 / $1,164.76 / $1,474.35
| Professional | | $1,148.34 | $1,164.76 | $1,474.35 |
- 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
- $2,372.00 / $2,846.00 / $4,583.00
| Professional | | $2,372.00 | $2,846.00 | $4,583.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.16 / $2,368.79 / $2,942.68
| Professional | | $1,458.16 | $2,368.79 | $2,942.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.47 / $2,370.29 / $4,085.91
| Professional | | $1,667.47 | $2,370.29 | $4,085.91 |