- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.77 / $704.50 / $904.81
| Professional | | $686.77 | $704.50 | $904.81 |
- 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
- $1,315.00 / $1,578.00 / $2,387.00
| Professional | | $1,315.00 | $1,578.00 | $2,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.38 / $1,212.56 / $1,933.27
| Professional | | $808.38 | $1,212.56 | $1,933.27 |
- 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
- $742.76 / $1,287.89 / $2,047.50
| Professional | | $742.76 | $1,287.89 | $2,047.50 |