- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $646.30 / $663.47 / $853.04
| Professional | | $646.30 | $663.47 | $853.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.60 / $1,373.60 / $1,373.60
| Facility | | $1,373.60 | $1,373.60 | $1,373.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.00 / $1,484.00 / $2,246.00
| Professional | | $1,237.00 | $1,484.00 | $2,246.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.94 / $1,181.91 / $1,819.78
| Professional | | $787.94 | $1,181.91 | $1,819.78 |
- 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
- $656.55 / $1,212.66 / $1,885.01
| Professional | | $656.55 | $1,212.66 | $1,885.01 |