- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.19 / $725.17 / $930.16
| Professional | | $706.19 | $725.17 | $930.16 |
- 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
- $1,352.00 / $1,622.00 / $2,455.00
| Professional | | $1,352.00 | $1,622.00 | $2,455.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.40 / $1,296.60 / $1,987.35
| Professional | | $864.40 | $1,296.60 | $1,987.35 |
- 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
- $762.18 / $1,312.55 / $2,113.79
| Professional | | $762.18 | $1,312.55 | $2,113.79 |