- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.00 / $1,066.27 / $1,381.81
| Professional | | $1,056.00 | $1,066.27 | $1,381.81 |
- 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
- $2,188.00 / $2,626.00 / $4,228.00
| Professional | | $2,188.00 | $2,626.00 | $4,228.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.36 / $2,207.01 / $2,738.13
| Professional | | $1,392.36 | $2,207.01 | $2,738.13 |
- 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
- $1,330.15 / $2,179.42 / $3,923.38
| Professional | | $1,330.15 | $2,179.42 | $3,923.38 |