- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.65 / $766.61 / $969.10
| Professional | | $762.65 | $766.61 | $969.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.20 / $2,767.20 / $2,767.20
| Facility | | $2,767.20 | $2,767.20 | $2,767.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.00 / $1,759.00 / $2,662.00
| Professional | | $1,466.00 | $1,759.00 | $2,662.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.18 / $1,525.30 / $2,124.44
| Professional | | $1,024.18 | $1,525.30 | $2,124.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.40 / $1,503.80 / $2,674.11
| Professional | | $992.40 | $1,503.80 | $2,674.11 |