- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.12 / $635.41 / $807.23
| Professional | | $635.12 | $635.41 | $807.23 |
- 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
- $1,214.00 / $1,457.00 / $2,204.00
| Professional | | $1,214.00 | $1,457.00 | $2,204.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.28 / $1,270.25 / $1,761.91
| Professional | | $851.28 | $1,270.25 | $1,761.91 |
- 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
- $705.32 / $1,253.75 / $2,083.89
| Professional | | $705.32 | $1,253.75 | $2,083.89 |