- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.02 / $812.62 / $1,046.40
| Professional | | $675.02 | $812.62 | $1,046.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,006.39 / $5,006.39 / $5,006.39
| Facility | | $5,006.39 | $5,006.39 | $5,006.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.00 / $1,523.00 / $2,304.00
| Professional | | $1,270.00 | $1,523.00 | $2,304.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.08 / $1,422.72 / $2,234.69
| Professional | | $1,030.08 | $1,422.72 | $2,234.69 |
- 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
- $1,111.77 / $1,647.29 / $2,958.81
| Professional | | $1,111.77 | $1,647.29 | $2,958.81 |