- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.28 / $2,181.07 / $3,238.75
| Professional | | $1,135.28 | $2,181.07 | $3,238.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $513.90 / $513.90 / $1,695.68
| Facility | | $513.90 | $513.90 | $1,695.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.90 / $513.90 / $513.90
| Professional | | $513.90 | $513.90 | $513.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.17 / $1,453.51 / $2,707.33
| Professional | | $1,085.17 | $1,453.51 | $2,707.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,217.00 / $36,459.75 / $36,459.75
| Facility | | $10,217.00 | $36,459.75 | $36,459.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,651.75 / $19,651.75 / $19,651.75
| Professional | | $19,651.75 | $19,651.75 | $19,651.75 |