- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.59 / $3,190.41 / $3,988.02
| Professional | | $723.59 | $3,190.41 | $3,988.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.73 / $2,927.94 / $3,033.28
| Facility | | $524.73 | $2,927.94 | $3,033.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,728.85 / $8,197.86 / $8,197.86
| Professional | | $2,728.85 | $8,197.86 | $8,197.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,275.00 / $3,275.00 / $3,275.00
| Facility | | $3,275.00 | $3,275.00 | $3,275.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.28 / $2,802.74 / $3,015.00
| Professional | | $492.28 | $2,802.74 | $3,015.00 |