- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.16 / $1,254.11 / $1,586.37
| Professional | | $1,235.16 | $1,254.11 | $1,586.37 |
- 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
- $2,552.00 / $3,062.00 / $4,930.00
| Professional | | $2,552.00 | $3,062.00 | $4,930.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.21 / $2,549.48 / $3,163.55
| Professional | | $1,565.21 | $2,549.48 | $3,163.55 |
- 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
- $1,797.32 / $2,554.88 / $4,357.60
| Professional | | $1,797.32 | $2,554.88 | $4,357.60 |