- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.14 / $1,290.72 / $1,628.43
| Professional | | $1,285.14 | $1,290.72 | $1,628.43 |
- 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
- $2,466.00 / $2,959.00 / $4,477.00
| Professional | | $2,466.00 | $2,959.00 | $4,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,759.56 / $2,581.44 / $3,561.22
| Professional | | $1,759.56 | $2,581.44 | $3,561.22 |
- 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
- $1,468.73 / $2,571.59 / $4,339.39
| Professional | | $1,468.73 | $2,571.59 | $4,339.39 |