- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.57 / $622.58 / $781.60
| Professional | | $620.57 | $622.58 | $781.60 |
- 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
- $1,193.00 / $1,432.00 / $2,165.00
| Professional | | $1,193.00 | $1,432.00 | $2,165.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.14 / $1,245.16 / $1,717.79
| Professional | | $844.14 | $1,245.16 | $1,717.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.84 / $1,239.11 / $2,144.98
| Professional | | $690.84 | $1,239.11 | $2,144.98 |