- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.59 / $531.79 / $669.40
| Professional | | $525.59 | $531.79 | $669.40 |
- 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
- $1,010.00 / $1,212.00 / $1,834.00
| Professional | | $1,010.00 | $1,212.00 | $1,834.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.37 / $1,040.05 / $1,470.73
| Professional | | $693.37 | $1,040.05 | $1,470.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.95 / $1,031.57 / $1,705.59
| Professional | | $555.95 | $1,031.57 | $1,705.59 |