- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,467.37 / $4,365.16
| Professional | | $1,698.24 | $3,467.37 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $50,118.72 / $50,118.72
| Facility | | $8,511.38 | $50,118.72 | $50,118.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Professional | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,778.28 / $2,344.23
| Professional | | $891.25 | $1,778.28 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,000.00 / $1,380.38
| Professional | | $831.76 | $1,000.00 | $1,380.38 |