- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.09 / $703.72 / $903.96
| Professional | | $687.09 | $703.72 | $903.96 |
- 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
- $1,317.00 / $1,580.00 / $2,390.00
| Professional | | $1,317.00 | $1,580.00 | $2,390.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.67 / $1,259.50 / $1,937.02
| Professional | | $839.67 | $1,259.50 | $1,937.02 |
- 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
- $761.24 / $1,296.25 / $2,060.51
| Professional | | $761.24 | $1,296.25 | $2,060.51 |