- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $646.16 / $646.85 / $819.06
| Professional | | $646.16 | $646.85 | $819.06 |
- 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
- $1,237.00 / $1,484.00 / $2,245.00
| Professional | | $1,237.00 | $1,484.00 | $2,245.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.47 / $1,292.32 / $1,792.63
| Professional | | $865.47 | $1,292.32 | $1,792.63 |
- 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
- $694.48 / $1,274.65 / $2,132.01
| Professional | | $694.48 | $1,274.65 | $2,132.01 |