- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $989.49 / $1,003.95 / $1,245.68
| Professional | | $989.49 | $1,003.95 | $1,245.68 |
- 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
- $1,901.00 / $2,281.00 / $3,452.00
| Professional | | $1,901.00 | $2,281.00 | $3,452.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.82 / $2,007.91 / $2,753.61
| Professional | | $1,386.82 | $2,007.91 | $2,753.61 |
- 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
- $1,118.73 / $2,042.92 / $3,759.58
| Professional | | $1,118.73 | $2,042.92 | $3,759.58 |