- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.81 / $1,100.88 / $1,385.52
| Professional | | $1,092.81 | $1,100.88 | $1,385.52 |
- 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
- $2,101.00 / $2,521.00 / $3,814.00
| Professional | | $2,101.00 | $2,521.00 | $3,814.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.67 / $2,201.76 / $3,032.27
| Professional | | $1,493.67 | $2,201.76 | $3,032.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.32 / $2,066.35 / $3,708.88
| Professional | | $1,255.32 | $2,066.35 | $3,708.88 |