- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.83 / $747.01 / $944.25
| Professional | | $746.83 | $747.01 | $944.25 |
- 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
- $1,430.00 / $1,716.00 / $2,596.00
| Professional | | $1,430.00 | $1,716.00 | $2,596.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.44 / $1,493.66 / $2,069.73
| Professional | | $1,007.44 | $1,493.66 | $2,069.73 |
- 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
- $833.24 / $1,478.03 / $2,473.89
| Professional | | $833.24 | $1,478.03 | $2,473.89 |