- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.75 / $797.06 / $1,007.62
| Professional | | $795.75 | $797.06 | $1,007.62 |
- 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
- $1,523.00 / $1,828.00 / $2,766.00
| Professional | | $1,523.00 | $1,828.00 | $2,766.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.14 / $1,594.12 / $2,204.02
| Professional | | $1,077.14 | $1,594.12 | $2,204.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.67 / $1,581.11 / $2,674.11
| Professional | | $906.67 | $1,581.11 | $2,674.11 |