- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.63 / $1,070.13 / $1,355.66
| Professional | | $1,055.63 | $1,070.13 | $1,355.66 |
- 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
- $2,180.00 / $2,616.00 / $4,211.00
| Professional | | $2,180.00 | $2,616.00 | $4,211.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.95 / $2,177.13 / $2,704.84
| Professional | | $1,336.95 | $2,177.13 | $2,704.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $12,808.14 / $18,767.00
| Facility | | $5,188.00 | $12,808.14 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.67 / $2,175.96 / $3,724.50
| Professional | | $1,230.67 | $2,175.96 | $3,724.50 |