- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $1,288.25
| Professional | | $891.25 | $891.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $954.99 / $1,348.96
| Facility | | $602.56 | $954.99 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.03 / $851.14 / $1,659.59
| Professional | | $6.03 | $851.14 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $28,840.32
| Facility | | $11,748.98 | $11,748.98 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,162.28
| Professional | | $2,884.03 | $2,884.03 | $3,162.28 |