- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.54 / $1,626.06 / $2,098.88
| Professional | | $1,601.54 | $1,626.06 | $2,098.88 |
- 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
- $3,061.00 / $3,673.00 / $5,557.00
| Professional | | $3,061.00 | $3,673.00 | $5,557.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.71 / $3,176.57 / $4,449.54
| Professional | | $2,117.71 | $3,176.57 | $4,449.54 |
- 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
- $2,297.61 / $3,266.02 / $5,434.00
| Professional | | $2,297.61 | $3,266.02 | $5,434.00 |