- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,483.74 / $1,523.24 / $1,870.31
| Professional | | $1,483.74 | $1,523.24 | $1,870.31 |
- 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
- $3,121.00 / $3,745.00 / $6,029.00
| Professional | | $3,121.00 | $3,745.00 | $6,029.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.58 / $2,604.86 / $3,796.65
| Professional | | $1,736.58 | $2,604.86 | $3,796.65 |
- 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
- $1,574.58 / $3,045.93 / $4,734.60
| Professional | | $1,574.58 | $3,045.93 | $4,734.60 |