- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.82 / $1,236.74 / $1,560.55
| Professional | | $1,232.82 | $1,236.74 | $1,560.55 |
- 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
- $2,365.00 / $2,838.00 / $4,294.00
| Professional | | $2,365.00 | $2,838.00 | $4,294.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.66 / $2,473.48 / $3,417.27
| Professional | | $1,681.66 | $2,473.48 | $3,417.27 |
- 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
- $1,393.63 / $2,460.13 / $4,157.41
| Professional | | $1,393.63 | $2,460.13 | $4,157.41 |