- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.13 / $796.32 / $1,006.05
| Professional | | $796.13 | $796.32 | $1,006.05 |
- 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
- $1,523.00 / $1,828.00 / $2,766.00
| Professional | | $1,523.00 | $1,828.00 | $2,766.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.20 / $1,592.26 / $2,204.91
| Professional | | $1,082.20 | $1,592.26 | $2,204.91 |
- 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
- $877.76 / $1,577.64 / $2,646.79
| Professional | | $877.76 | $1,577.64 | $2,646.79 |