- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.36 / $746.17 / $941.92
| Professional | | $743.36 | $746.17 | $941.92 |
- 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
- $1,425.00 / $1,710.00 / $2,587.00
| Professional | | $1,425.00 | $1,710.00 | $2,587.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.12 / $1,486.71 / $2,066.42
| Professional | | $1,000.12 | $1,486.71 | $2,066.42 |
- 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
- $1,032.43 / $1,482.80 / $2,386.81
| Professional | | $1,032.43 | $1,482.80 | $2,386.81 |