- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.03 / $953.86 / $1,212.46
| Professional | | $947.03 | $953.86 | $1,212.46 |
- 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
- $1,949.00 / $2,339.00 / $3,766.00
| Professional | | $1,949.00 | $2,339.00 | $3,766.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.59 / $1,944.10 / $2,423.67
| Professional | | $1,194.59 | $1,944.10 | $2,423.67 |
- 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
- $1,114.16 / $1,936.35 / $3,009.87
| Professional | | $1,114.16 | $1,936.35 | $3,009.87 |