- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,591.70 / $1,989.63 / $3,332.00
| Professional | | $1,591.70 | $1,989.63 | $3,332.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,851.75 / $13,851.75 / $13,851.75
| Facility | | $13,851.75 | $13,851.75 | $13,851.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,783.07 / $3,783.07 / $3,783.07
| Professional | | $3,783.07 | $3,783.07 | $3,783.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $854.85 / $1,265.00 / $1,674.68
| Facility | | $854.85 | $1,265.00 | $1,674.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.43 / $1,389.01 / $1,674.68
| Professional | | $1,024.43 | $1,389.01 | $1,674.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $1,003.70 / $1,881.90
| Professional | | $7.00 | $1,003.70 | $1,881.90 |