- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.94 / $1,049.31 / $1,377.56
| Professional | | $1,010.94 | $1,049.31 | $1,377.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,006.39 / $5,006.39 / $5,006.39
| Facility | | $5,006.39 | $5,006.39 | $5,006.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,928.00 / $2,314.00 / $3,500.00
| Professional | | $1,928.00 | $2,314.00 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.71 / $2,098.63 / $2,805.35
| Professional | | $1,458.71 | $2,098.63 | $2,805.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.44 / $2,219.13 / $3,933.78
| Professional | | $1,331.44 | $2,219.13 | $3,933.78 |