- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,339.42 / $1,360.05 / $1,720.05
| Professional | | $1,339.42 | $1,360.05 | $1,720.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,694.40 / $5,694.40 / $5,694.40
| Facility | | $5,694.40 | $5,694.40 | $5,694.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,768.00 / $3,322.00 / $5,346.00
| Professional | | $2,768.00 | $3,322.00 | $5,346.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.88 / $2,349.69 / $3,430.18
| Professional | | $1,554.88 | $2,349.69 | $3,430.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.20 / $2,800.92 / $4,906.18
| Professional | | $1,706.20 | $2,800.92 | $4,906.18 |