- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,047.13 / $2,344.23
| Professional | | $977.24 | $1,047.13 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Facility | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,388.44 / $4,073.80
| Professional | | $2,137.96 | $3,388.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,949.84 / $2,630.27
| Professional | | $1,288.25 | $1,949.84 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,495.41 / $18,197.01
| Facility | | $5,128.61 | $5,495.41 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,905.46 / $4,073.80
| Professional | | $1,148.15 | $1,905.46 | $4,073.80 |