- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.08 / $921.74 / $1,149.28
| Professional | | $793.08 | $921.74 | $1,149.28 |
- 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
- $1,513.00 / $1,747.00 / $2,643.00
| Professional | | $1,513.00 | $1,747.00 | $2,643.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.76 / $1,600.14 / $2,540.25
| Professional | | $1,066.76 | $1,600.14 | $2,540.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.72 / $1,763.61 / $2,900.28
| Professional | | $966.72 | $1,763.61 | $2,900.28 |