- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.81 / $869.40 / $1,023.63
| Professional | | $776.81 | $869.40 | $1,023.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,753.00 / $8,753.00 / $8,753.00
| Professional | | $8,753.00 | $8,753.00 | $8,753.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,401.97 / $27,401.97 / $27,401.97
| Facility | | $27,401.97 | $27,401.97 | $27,401.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.43 / $1,204.03 / $1,858.09
| Professional | | $945.43 | $1,204.03 | $1,858.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.88 / $1,034.15 / $1,540.57
| Professional | | $746.88 | $1,034.15 | $1,540.57 |