- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.87 / $828.39 / $1,059.45
| Professional | | $806.87 | $828.39 | $1,059.45 |
- 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
- $1,548.00 / $1,858.00 / $2,810.00
| Professional | | $1,548.00 | $1,858.00 | $2,810.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.94 / $1,514.91 / $2,267.51
| Professional | | $1,009.94 | $1,514.91 | $2,267.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.08 / $1,540.72 / $2,394.90
| Professional | | $854.08 | $1,540.72 | $2,394.90 |