- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.70 / $663.07 / $839.20
| Professional | | $657.70 | $663.07 | $839.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.60 / $1,373.60 / $1,373.60
| Facility | | $1,373.60 | $1,373.60 | $1,373.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.00 / $1,511.00 / $2,285.00
| Professional | | $1,259.00 | $1,511.00 | $2,285.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.53 / $1,183.14 / $1,832.97
| Professional | | $833.53 | $1,183.14 | $1,832.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.28 / $1,183.67 / $1,961.82
| Professional | | $656.28 | $1,183.67 | $1,961.82 |