- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.44 / $875.46 / $1,108.23
| Professional | | $873.44 | $875.46 | $1,108.23 |
- 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
- $1,673.00 / $2,008.00 / $3,037.00
| Professional | | $1,673.00 | $2,008.00 | $3,037.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.38 / $1,746.89 / $2,425.94
| Professional | | $1,171.38 | $1,746.89 | $2,425.94 |
- 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
- $929.86 / $1,723.91 / $2,823.60
| Professional | | $929.86 | $1,723.91 | $2,823.60 |