- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,288.25 / $2,754.23
| Professional | | $1,122.02 | $1,288.25 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,265.80 / $4,265.80
| Professional | | $2,818.38 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,238.72 / $3,388.44
| Professional | | $1,479.11 | $2,238.72 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $12,022.64 / $25,703.96
| Facility | | $6,918.31 | $12,022.64 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,187.76 / $4,677.35
| Professional | | $1,348.96 | $2,187.76 | $4,677.35 |