- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.91 / $957.83 / $1,207.23
| Professional | | $952.91 | $957.83 | $1,207.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.20 / $2,767.20 / $2,767.20
| Facility | | $2,767.20 | $2,767.20 | $2,767.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,827.00 / $2,192.00 / $3,317.00
| Professional | | $1,827.00 | $2,192.00 | $3,317.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.96 / $1,915.66 / $2,640.26
| Professional | | $1,291.96 | $1,915.66 | $2,640.26 |
- 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
- $1,115.56 / $1,690.12 / $2,996.49
| Professional | | $1,115.56 | $1,690.12 | $2,996.49 |