- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.21 / $1,131.36 / $1,424.02
| Professional | | $1,122.21 | $1,131.36 | $1,424.02 |
- 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
- $2,157.00 / $2,588.00 / $3,916.00
| Professional | | $2,157.00 | $2,588.00 | $3,916.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.04 / $2,262.73 / $3,112.73
| Professional | | $1,539.04 | $2,262.73 | $3,112.73 |
- 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
- $1,295.09 / $2,251.89 / $3,820.68
| Professional | | $1,295.09 | $2,251.89 | $3,820.68 |