- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.31 / $1,025.98 / $1,294.59
| Professional | | $1,022.31 | $1,025.98 | $1,294.59 |
- 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
- $1,958.00 / $2,350.00 / $3,556.00
| Professional | | $1,958.00 | $2,350.00 | $3,556.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.98 / $2,051.96 / $2,833.04
| Professional | | $1,377.98 | $2,051.96 | $2,833.04 |
- 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
- $1,284.20 / $2,030.38 / $3,548.99
| Professional | | $1,284.20 | $2,030.38 | $3,548.99 |