- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,071.52 / $1,862.09
| Professional | | $977.24 | $1,071.52 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,715.35 / $3,715.35
| Professional | | $2,454.71 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,949.84 / $2,951.21
| Professional | | $1,258.93 | $1,949.84 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $12,022.64 / $18,197.01
| Facility | | $5,128.61 | $12,022.64 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,905.46 / $3,715.35
| Professional | | $1,148.15 | $1,905.46 | $3,715.35 |