- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.81 / $746.77 / $965.39
| Professional | | $724.81 | $746.77 | $965.39 |
- 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
- $1,390.00 / $1,668.00 / $2,524.00
| Professional | | $1,390.00 | $1,668.00 | $2,524.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.84 / $1,385.76 / $2,043.64
| Professional | | $923.84 | $1,385.76 | $2,043.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.40 / $1,375.65 / $2,256.78
| Professional | | $830.40 | $1,375.65 | $2,256.78 |