- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.16 / $738.31 / $934.64
| Professional | | $733.16 | $738.31 | $934.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.60 / $1,373.60 / $1,373.60
| Facility | | $1,373.60 | $1,373.60 | $1,373.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.00 / $1,688.00 / $2,554.00
| Professional | | $1,407.00 | $1,688.00 | $2,554.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.81 / $1,466.32 / $2,043.46
| Professional | | $978.81 | $1,466.32 | $2,043.46 |
- 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
- $785.39 / $1,442.52 / $2,381.59
| Professional | | $785.39 | $1,442.52 | $2,381.59 |