- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.26 / $1,109.56 / $1,405.75
| Professional | | $1,095.26 | $1,109.56 | $1,405.75 |
- 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
- $2,261.00 / $2,713.00 / $4,368.00
| Professional | | $2,261.00 | $2,713.00 | $4,368.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.33 / $2,257.48 / $2,806.32
| Professional | | $1,386.33 | $2,257.48 | $2,806.32 |
- 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
- $1,284.20 / $2,257.44 / $3,815.50
| Professional | | $1,284.20 | $2,257.44 | $3,815.50 |