- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.71 / $585.04 / $739.45
| Professional | | $582.71 | $585.04 | $739.45 |
- 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
- $1,117.00 / $1,340.00 / $2,027.00
| Professional | | $1,117.00 | $1,340.00 | $2,027.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.60 / $1,165.42 / $1,620.91
| Professional | | $777.60 | $1,165.42 | $1,620.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.87 / $1,145.08 / $1,903.20
| Professional | | $650.87 | $1,145.08 | $1,903.20 |