- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.15 / $1,020.40 / $1,285.86
| Professional | | $1,015.15 | $1,020.40 | $1,285.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,931.20 / $15,931.20 / $15,931.20
| Facility | | $15,931.20 | $15,931.20 | $15,931.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.00 / $2,335.00 / $3,533.00
| Professional | | $1,946.00 | $2,335.00 | $3,533.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.09 / $2,040.81 / $2,811.78
| Professional | | $1,380.09 | $2,040.81 | $2,811.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,509.00 / $8,509.00 / $27,952.00
| Facility | | $8,509.00 | $8,509.00 | $27,952.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.25 / $1,746.01 / $3,438.50
| Professional | | $1,157.25 | $1,746.01 | $3,438.50 |