- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.47 / $1,040.36 / $1,318.86
| Professional | | $1,027.47 | $1,040.36 | $1,318.86 |
- 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
- $2,123.00 / $2,548.00 / $4,100.00
| Professional | | $2,123.00 | $2,548.00 | $4,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.58 / $2,117.54 / $2,633.70
| Professional | | $1,300.58 | $2,117.54 | $2,633.70 |
- 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
- $1,221.44 / $2,115.36 / $3,608.79
| Professional | | $1,221.44 | $2,115.36 | $3,608.79 |