- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.94 / $1,023.91 / $1,305.27
| Professional | | $1,016.94 | $1,023.91 | $1,305.27 |
- 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
- $1,931.00 / $2,317.00 / $3,506.00
| Professional | | $1,931.00 | $2,317.00 | $3,506.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.36 / $2,047.81 / $2,823.81
| Professional | | $1,406.36 | $2,047.81 | $2,823.81 |
- 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
- $1,168.61 / $2,033.87 / $3,443.68
| Professional | | $1,168.61 | $2,033.87 | $3,443.68 |