- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.78 / $680.67 / $858.74
| Professional | | $675.78 | $680.67 | $858.74 |
- 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
- $1,294.00 / $1,553.00 / $2,350.00
| Professional | | $1,294.00 | $1,553.00 | $2,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.59 / $1,351.56 / $1,880.16
| Professional | | $916.59 | $1,351.56 | $1,880.16 |
- 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
- $906.18 / $1,336.64 / $2,406.31
| Professional | | $906.18 | $1,336.64 | $2,406.31 |