- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.82 / $573.35 / $725.30
| Professional | | $570.82 | $573.35 | $725.30 |
- 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
- $1,095.00 / $1,314.00 / $1,988.00
| Professional | | $1,095.00 | $1,314.00 | $1,988.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.38 / $1,134.57 / $1,589.67
| Professional | | $756.38 | $1,134.57 | $1,589.67 |
- 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
- $788.41 / $1,132.33 / $2,012.39
| Professional | | $788.41 | $1,132.33 | $2,012.39 |