- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.80 / $930.06 / $1,173.28
| Professional | | $925.80 | $930.06 | $1,173.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,251.20 / $11,251.20 / $11,251.20
| Facility | | $11,251.20 | $11,251.20 | $11,251.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.00 / $2,131.00 / $3,223.00
| Professional | | $1,776.00 | $2,131.00 | $3,223.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.73 / $1,860.12 / $2,567.16
| Professional | | $1,252.73 | $1,860.12 | $2,567.16 |
- 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
- $995.60 / $1,790.10 / $3,243.50
| Professional | | $995.60 | $1,790.10 | $3,243.50 |