- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.09 / $534.54 / $671.13
| Professional | | $528.09 | $534.54 | $671.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.60 / $1,373.60 / $1,373.60
| Facility | | $1,373.60 | $1,373.60 | $1,373.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.00 / $1,220.00 / $1,846.00
| Professional | | $1,017.00 | $1,220.00 | $1,846.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.60 / $950.39 / $1,478.90
| Professional | | $633.60 | $950.39 | $1,478.90 |
- 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
- $532.44 / $1,030.86 / $1,602.39
| Professional | | $532.44 | $1,030.86 | $1,602.39 |