- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.38 / $580.14 / $735.29
| Professional | | $578.38 | $580.14 | $735.29 |
- 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
- $1,109.00 / $1,331.00 / $2,014.00
| Professional | | $1,109.00 | $1,331.00 | $2,014.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.10 / $1,152.16 / $1,610.41
| Professional | | $768.10 | $1,152.16 | $1,610.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $5,606.00 / $6,489.22
| Facility | | $1,275.00 | $5,606.00 | $6,489.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.23 / $1,134.65 / $1,874.61
| Professional | | $626.23 | $1,134.65 | $1,874.61 |