- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.79 / $535.66 / $676.32
| Professional | | $531.79 | $535.66 | $676.32 |
- 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
- $1,021.00 / $1,225.00 / $1,854.00
| Professional | | $1,021.00 | $1,225.00 | $1,854.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.09 / $1,056.13 / $1,484.04
| Professional | | $704.09 | $1,056.13 | $1,484.04 |
- 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
- $725.23 / $1,042.01 / $1,872.00
| Professional | | $725.23 | $1,042.01 | $1,872.00 |