- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.20 / $520.91 / $657.44
| Professional | | $516.20 | $520.91 | $657.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.20 / $2,767.20 / $2,767.20
| Facility | | $2,767.20 | $2,767.20 | $2,767.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.00 / $1,190.00 / $1,800.00
| Professional | | $992.00 | $1,190.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.10 / $1,023.14 / $1,442.71
| Professional | | $682.10 | $1,023.14 | $1,442.71 |
- 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
- $557.48 / $1,009.97 / $1,647.10
| Professional | | $557.48 | $1,009.97 | $1,647.10 |