- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.22 / $919.61 / $1,160.84
| Professional | | $916.22 | $919.61 | $1,160.84 |
- 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
- $1,757.00 / $2,108.00 / $3,188.00
| Professional | | $1,757.00 | $2,108.00 | $3,188.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.91 / $1,839.21 / $2,540.42
| Professional | | $1,237.91 | $1,839.21 | $2,540.42 |
- 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
- $1,137.01 / $1,821.42 / $3,208.38
| Professional | | $1,137.01 | $1,821.42 | $3,208.38 |