- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.48 / $748.07 / $931.95
| Professional | | $736.48 | $748.07 | $931.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.80 / $2,428.80 / $2,428.80
| Facility | | $2,428.80 | $2,428.80 | $2,428.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,423.00 / $1,708.00 / $2,584.00
| Professional | | $1,423.00 | $1,708.00 | $2,584.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.73 / $1,496.14 / $2,042.91
| Professional | | $1,011.73 | $1,496.14 | $2,042.91 |
- 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
- $917.33 / $1,489.19 / $2,622.11
| Professional | | $917.33 | $1,489.19 | $2,622.11 |