- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.10 / $1,070.51 / $1,349.83
| Professional | | $1,065.10 | $1,070.51 | $1,349.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,251.20 / $11,251.20 / $11,251.20
| Facility | | $11,251.20 | $11,251.20 | $11,251.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.00 / $2,453.00 / $3,710.00
| Professional | | $2,044.00 | $2,453.00 | $3,710.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.41 / $2,141.01 / $2,952.74
| Professional | | $1,450.41 | $2,141.01 | $2,952.74 |
- 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
- $1,207.80 / $1,996.81 / $3,568.49
| Professional | | $1,207.80 | $1,996.81 | $3,568.49 |