- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.79 / $531.14 / $660.80
| Professional | | $529.79 | $531.14 | $660.80 |
- 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
- $1,017.00 / $1,220.00 / $1,847.00
| Professional | | $1,017.00 | $1,220.00 | $1,847.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.06 / $1,059.59 / $1,482.64
| Professional | | $715.06 | $1,059.59 | $1,482.64 |
- 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
- $596.87 / $1,019.72 / $1,796.59
| Professional | | $596.87 | $1,019.72 | $1,796.59 |