- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.61 / $1,078.83 / $1,357.39
| Professional | | $1,070.61 | $1,078.83 | $1,357.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,116.00 / $6,116.00 / $6,116.00
| Facility | | $6,116.00 | $6,116.00 | $6,116.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.00 / $2,471.00 / $3,737.00
| Professional | | $2,059.00 | $2,471.00 | $3,737.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.42 / $2,157.69 / $2,969.36
| Professional | | $1,462.42 | $2,157.69 | $2,969.36 |
- 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
- $1,242.11 / $2,044.25 / $3,669.89
| Professional | | $1,242.11 | $2,044.25 | $3,669.89 |