- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.47 / $1,063.50 / $1,334.91
| Professional | | $1,044.47 | $1,063.50 | $1,334.91 |
- 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
- $1,992.00 / $2,390.00 / $3,617.00
| Professional | | $1,992.00 | $2,390.00 | $3,617.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,433.29 / $2,127.00 / $2,908.38
| Professional | | $1,433.29 | $2,127.00 | $2,908.38 |
- 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
- $1,288.94 / $2,024.80 / $3,650.39
| Professional | | $1,288.94 | $2,024.80 | $3,650.39 |