- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.26 / $981.32 / $1,237.60
| Professional | | $975.26 | $981.32 | $1,237.60 |
- 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
- $1,871.00 / $2,245.00 / $3,397.00
| Professional | | $1,871.00 | $2,245.00 | $3,397.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.34 / $1,962.65 / $2,704.47
| Professional | | $1,326.34 | $1,962.65 | $2,704.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.53 / $1,948.20 / $3,491.81
| Professional | | $1,370.53 | $1,948.20 | $3,491.81 |