- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.96 / $1,116.76 / $1,401.06
| Professional | | $1,107.96 | $1,116.76 | $1,401.06 |
- 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
- $2,138.00 / $2,566.00 / $3,882.00
| Professional | | $2,138.00 | $2,566.00 | $3,882.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.46 / $2,215.92 / $3,094.41
| Professional | | $1,505.46 | $2,215.92 | $3,094.41 |
- 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
- $1,197.76 / $2,198.94 / $3,707.61
| Professional | | $1,197.76 | $2,198.94 | $3,707.61 |