- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.75 / $1,253.82 / $1,457.55
| Professional | | $1,073.75 | $1,253.82 | $1,457.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,474.57 / $4,692.88 / $5,555.81
| Facility | | $3,474.57 | $4,692.88 | $5,555.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.78 / $1,291.50 / $2,159.92
| Professional | | $1,097.78 | $1,291.50 | $2,159.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,421.48 / $1,620.00 / $1,620.00
| Facility | | $1,421.48 | $1,620.00 | $1,620.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.59 / $1,620.00 / $1,620.00
| Professional | | $1,182.59 | $1,620.00 | $1,620.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.46 / $2,783.46 / $2,783.46
| Facility | | $2,783.46 | $2,783.46 | $2,783.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.10 / $1,403.46 / $2,043.38
| Professional | | $1,108.10 | $1,403.46 | $2,043.38 |