- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.07 / $1,054.48 / $1,328.67
| Professional | | $1,015.07 | $1,054.48 | $1,328.67 |
- 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
- $1,962.00 / $2,354.00 / $3,562.00
| Professional | | $1,962.00 | $2,354.00 | $3,562.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.51 / $1,838.26 / $2,878.83
| Professional | | $1,225.51 | $1,838.26 | $2,878.83 |
- 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
- $1,073.86 / $1,908.50 / $3,181.10
| Professional | | $1,073.86 | $1,908.50 | $3,181.10 |