- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.47 / $777.08 / $982.74
| Professional | | $776.47 | $777.08 | $982.74 |
- 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
- $1,486.00 / $1,783.00 / $2,699.00
| Professional | | $1,486.00 | $1,783.00 | $2,699.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.70 / $1,554.16 / $2,151.67
| Professional | | $1,048.70 | $1,554.16 | $2,151.67 |
- 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
- $981.92 / $1,537.94 / $2,748.19
| Professional | | $981.92 | $1,537.94 | $2,748.19 |