- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.78 / $538.63 / $674.06
| Professional | | $532.78 | $538.63 | $674.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.80 / $2,428.80 / $2,428.80
| Facility | | $2,428.80 | $2,428.80 | $2,428.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.00 / $1,229.00 / $1,859.00
| Professional | | $1,024.00 | $1,229.00 | $1,859.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.90 / $1,077.27 / $1,480.77
| Professional | | $723.90 | $1,077.27 | $1,480.77 |
- 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
- $581.03 / $1,060.10 / $1,738.10
| Professional | | $581.03 | $1,060.10 | $1,738.10 |