- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.77 / $588.35 / $743.58
| Professional | | $585.77 | $588.35 | $743.58 |
- 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
- $1,123.00 / $1,348.00 / $2,039.00
| Professional | | $1,123.00 | $1,348.00 | $2,039.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.49 / $1,170.74 / $1,630.12
| Professional | | $780.49 | $1,170.74 | $1,630.12 |
- 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
- $634.28 / $1,066.64 / $1,891.50
| Professional | | $634.28 | $1,066.64 | $1,891.50 |