- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.06 / $827.36 / $1,045.69
| Professional | | $826.06 | $827.36 | $1,045.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,251.20 / $11,251.20 / $11,251.20
| Facility | | $11,251.20 | $11,251.20 | $11,251.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.00 / $1,900.00 / $2,874.00
| Professional | | $1,583.00 | $1,900.00 | $2,874.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.96 / $1,654.73 / $2,289.50
| Professional | | $1,118.96 | $1,654.73 | $2,289.50 |
- 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
- $942.19 / $1,634.75 / $2,767.68
| Professional | | $942.19 | $1,634.75 | $2,767.68 |