- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.36 / $743.76 / $940.96
| Professional | | $743.36 | $743.76 | $940.96 |
- 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
- $1,422.00 / $1,706.00 / $2,581.00
| Professional | | $1,422.00 | $1,706.00 | $2,581.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.85 / $1,263.70 / $2,061.60
| Professional | | $793.85 | $1,263.70 | $2,061.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $6,489.22 / $18,767.00
| Facility | | $5,188.00 | $6,489.22 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.50 / $1,462.71 / $2,273.64
| Professional | | $864.50 | $1,462.71 | $2,273.64 |