- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.32 / $829.11 / $1,068.73
| Professional | | $807.32 | $829.11 | $1,068.73 |
- 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
- $1,546.00 / $1,855.00 / $2,808.00
| Professional | | $1,546.00 | $1,855.00 | $2,808.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.88 / $1,468.31 / $2,270.31
| Professional | | $978.88 | $1,468.31 | $2,270.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.35 / $1,541.41 / $2,485.60
| Professional | | $903.35 | $1,541.41 | $2,485.60 |