- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.39 / $1,017.02 / $1,245.93
| Professional | | $972.39 | $1,017.02 | $1,245.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,694.40 / $5,694.40 / $5,694.40
| Facility | | $5,694.40 | $5,694.40 | $5,694.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.00 / $2,437.00 / $3,923.00
| Professional | | $2,031.00 | $2,437.00 | $3,923.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.19 / $2,004.57 / $2,536.10
| Professional | | $1,310.19 | $2,004.57 | $2,536.10 |
- 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
- $1,431.78 / $1,811.65 / $3,669.89
| Professional | | $1,431.78 | $1,811.65 | $3,669.89 |