- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.12 / $835.55 / $1,056.35
| Professional | | $830.12 | $835.55 | $1,056.35 |
- 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
- $1,592.00 / $1,910.00 / $2,890.00
| Professional | | $1,592.00 | $1,910.00 | $2,890.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.27 / $1,653.40 / $2,314.36
| Professional | | $1,102.27 | $1,653.40 | $2,314.36 |
- 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
- $878.19 / $1,627.09 / $2,663.71
| Professional | | $878.19 | $1,627.09 | $2,663.71 |