- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.16 / $1,135.46 / $1,429.27
| Professional | | $1,126.16 | $1,135.46 | $1,429.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.20 / $2,767.20 / $2,767.20
| Facility | | $2,767.20 | $2,767.20 | $2,767.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,165.00 / $2,598.00 / $3,931.00
| Professional | | $2,165.00 | $2,598.00 | $3,931.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,542.97 / $2,270.92 / $3,123.95
| Professional | | $1,542.97 | $2,270.92 | $3,123.95 |
- 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
- $1,591.03 / $2,285.07 / $3,824.59
| Professional | | $1,591.03 | $2,285.07 | $3,824.59 |