- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,354.04 / $1,354.04 / $2,648.18
| Professional | | $1,354.04 | $1,354.04 | $2,648.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,574.22 / $26,542.00 / $26,542.00
| Facility | | $6,574.22 | $26,542.00 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,178.67 / $5,178.67 / $5,178.67
| Professional | | $5,178.67 | $5,178.67 | $5,178.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.46 / $1,529.03 / $2,187.66
| Facility | | $1,174.46 | $1,529.03 | $2,187.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.50 / $1,572.50 / $1,572.50
| Professional | | $1,572.50 | $1,572.50 | $1,572.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.46 / $1,529.03 / $2,187.66
| Facility | | $1,174.46 | $1,529.03 | $2,187.66 |