- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $574.39 / $716.62 / $928.33
| Professional | | $574.39 | $716.62 | $928.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,752.00 / $2,752.00 / $2,752.00
| Facility | | $2,752.00 | $2,752.00 | $2,752.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.00 / $1,457.00 / $2,204.00
| Professional | | $1,165.00 | $1,457.00 | $2,204.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.13 / $1,117.41 / $2,065.48
| Professional | | $634.13 | $1,117.41 | $2,065.48 |
- 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
- $635.75 / $1,204.57 / $1,941.27
| Professional | | $635.75 | $1,204.57 | $1,941.27 |