- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.25 / $1,009.15 / $1,272.18
| Professional | | $1,003.25 | $1,009.15 | $1,272.18 |
- 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
- $1,924.00 / $2,309.00 / $3,493.00
| Professional | | $1,924.00 | $2,309.00 | $3,493.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.48 / $2,018.30 / $2,780.22
| Professional | | $1,365.48 | $2,018.30 | $2,780.22 |
- 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
- $1,292.72 / $1,952.60 / $3,543.81
| Professional | | $1,292.72 | $1,952.60 | $3,543.81 |