- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.66 / $610.12 / $770.56
| Professional | | $606.66 | $610.12 | $770.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.60 / $1,373.60 / $1,373.60
| Facility | | $1,373.60 | $1,373.60 | $1,373.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.00 / $1,397.00 / $2,113.00
| Professional | | $1,164.00 | $1,397.00 | $2,113.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.33 / $1,213.32 / $1,690.10
| Professional | | $816.33 | $1,213.32 | $1,690.10 |
- 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
- $838.38 / $1,191.76 / $2,138.50
| Professional | | $838.38 | $1,191.76 | $2,138.50 |