- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.63 / $785.96 / $1,006.22
| Professional | | $765.63 | $785.96 | $1,006.22 |
- 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
- $1,469.00 / $1,763.00 / $2,666.00
| Professional | | $1,469.00 | $1,763.00 | $2,666.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.31 / $1,425.46 / $2,153.19
| Professional | | $950.31 | $1,425.46 | $2,153.19 |
- 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
- $1,022.14 / $1,452.96 / $2,334.81
| Professional | | $1,022.14 | $1,452.96 | $2,334.81 |