- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.71 / $583.30 / $736.54
| Professional | | $579.71 | $583.30 | $736.54 |
- 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
- $1,112.00 / $1,334.00 / $2,020.00
| Professional | | $1,112.00 | $1,334.00 | $2,020.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.45 / $1,046.18 / $1,615.12
| Professional | | $697.45 | $1,046.18 | $1,615.12 |
- 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
- $615.34 / $1,138.82 / $1,883.70
| Professional | | $615.34 | $1,138.82 | $1,883.70 |