- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.08 / $873.36 / $1,116.27
| Professional | | $853.08 | $873.36 | $1,116.27 |
- 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
- $1,635.00 / $1,962.00 / $2,968.00
| Professional | | $1,635.00 | $1,962.00 | $2,968.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.08 / $1,555.62 / $2,392.39
| Professional | | $1,037.08 | $1,555.62 | $2,392.39 |
- 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
- $1,146.10 / $1,629.19 / $2,641.61
| Professional | | $1,146.10 | $1,629.19 | $2,641.61 |