- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $574.97 / $578.16 / $730.57
| Professional | | $574.97 | $578.16 | $730.57 |
- 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
- $1,104.00 / $1,325.00 / $2,004.00
| Professional | | $1,104.00 | $1,325.00 | $2,004.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.21 / $1,147.82 / $1,603.18
| Professional | | $765.21 | $1,147.82 | $1,603.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.12 / $1,128.36 / $1,813.51
| Professional | | $610.12 | $1,128.36 | $1,813.51 |