- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.75 / $1,020.27 / $1,286.82
| Professional | | $1,004.75 | $1,020.27 | $1,286.82 |
- 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
- $1,930.00 / $2,316.00 / $3,504.00
| Professional | | $1,930.00 | $2,316.00 | $3,504.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,372.27 / $2,040.54 / $2,792.52
| Professional | | $1,372.27 | $2,040.54 | $2,792.52 |
- 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
- $1,097.06 / $2,042.92 / $3,246.11
| Professional | | $1,097.06 | $2,042.92 | $3,246.11 |