- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,174.90 / $2,398.83
| Professional | | $1,023.29 | $1,174.90 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,890.45 / $3,890.45
| Professional | | $2,570.40 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,041.74 / $3,090.30
| Professional | | $1,318.26 | $2,041.74 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $12,022.64 / $18,197.01
| Facility | | $5,128.61 | $12,022.64 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,995.26 / $4,265.80
| Professional | | $1,202.26 | $1,995.26 | $4,265.80 |