- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.52 / $778.61 / $996.83
| Professional | | $767.52 | $778.61 | $996.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,006.39 / $5,006.39 / $5,006.39
| Facility | | $5,006.39 | $5,006.39 | $5,006.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.00 / $1,751.00 / $2,648.00
| Professional | | $1,459.00 | $1,751.00 | $2,648.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.94 / $1,557.22 / $2,140.71
| Professional | | $1,051.94 | $1,557.22 | $2,140.71 |
- 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
- $957.82 / $1,498.98 / $3,127.08
| Professional | | $957.82 | $1,498.98 | $3,127.08 |