- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $6,456.54 / $8,912.51
| Professional | | $891.25 | $6,456.54 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $776.25 / $933.25
| Professional | | $691.83 | $776.25 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $12,022.64 / $12,022.64
| Facility | | $12,022.64 | $12,022.64 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $13,803.84 / $19,054.61
| Professional | | $10,715.19 | $13,803.84 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $776.25 / $12,022.64
| Professional | | $478.63 | $776.25 | $12,022.64 |