- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,148.15 / $2,041.74
| Professional | | $1,047.13 | $1,148.15 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Facility | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,715.35 / $4,466.84
| Professional | | $2,290.87 | $3,715.35 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,137.96 / $2,884.03
| Professional | | $1,412.54 | $2,137.96 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,495.41 / $18,197.01
| Facility | | $5,128.61 | $5,495.41 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,041.74 / $4,365.16
| Professional | | $1,202.26 | $2,041.74 | $4,365.16 |