- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.59 / $937.50 / $1,195.53
| Professional | | $914.59 | $937.50 | $1,195.53 |
- 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
- $1,756.00 / $2,107.00 / $3,187.00
| Professional | | $1,756.00 | $2,107.00 | $3,187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.81 / $1,744.21 / $2,565.76
| Professional | | $1,162.81 | $1,744.21 | $2,565.76 |
- 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
- $1,016.56 / $1,765.44 / $2,871.69
| Professional | | $1,016.56 | $1,765.44 | $2,871.69 |