- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.95 / $1,622.35 / $2,063.64
| Professional | | $1,620.95 | $1,622.35 | $2,063.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,931.20 / $15,931.20 / $15,931.20
| Facility | | $15,931.20 | $15,931.20 | $15,931.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,196.00 / $3,835.00 / $5,802.00
| Professional | | $3,196.00 | $3,835.00 | $5,802.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.35 / $3,244.71 / $4,670.28
| Professional | | $2,260.35 | $3,244.71 | $4,670.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $18,767.00 / $36,780.10
| Facility | | $5,188.00 | $18,767.00 | $36,780.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,305.94 / $3,311.84 / $5,692.68
| Professional | | $2,305.94 | $3,311.84 | $5,692.68 |