- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.71 / $1,012.52 / $1,274.73
| Professional | | $1,006.71 | $1,012.52 | $1,274.73 |
- 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
- $1,933.00 / $2,320.00 / $3,510.00
| Professional | | $1,933.00 | $2,320.00 | $3,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,223.11 / $1,834.68 / $2,789.20
| Professional | | $1,223.11 | $1,834.68 | $2,789.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.50 / $1,880.45 / $3,273.40
| Professional | | $1,053.50 | $1,880.45 | $3,273.40 |