- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.48 / $907.74 / $1,160.93
| Professional | | $907.48 | $907.74 | $1,160.93 |
- 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
- $1,734.00 / $2,081.00 / $3,148.00
| Professional | | $1,734.00 | $2,081.00 | $3,148.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.34 / $1,749.52 / $2,521.01
| Professional | | $1,166.34 | $1,749.52 | $2,521.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.77 / $1,771.21 / $2,869.08
| Professional | | $1,039.77 | $1,771.21 | $2,869.08 |