- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.15 / $897.30 / $1,103.82
| Professional | | $867.15 | $897.30 | $1,103.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,116.00 / $6,116.00 / $6,116.00
| Facility | | $6,116.00 | $6,116.00 | $6,116.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.00 / $2,047.00 / $3,097.00
| Professional | | $1,706.00 | $2,047.00 | $3,097.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.50 / $1,694.26 / $2,451.73
| Professional | | $1,129.50 | $1,694.26 | $2,451.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.84 / $1,735.82 / $2,960.11
| Professional | | $1,231.84 | $1,735.82 | $2,960.11 |