- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.06 / $708.04 / $894.47
| Professional | | $707.06 | $708.04 | $894.47 |
- 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
- $950.04 / $1,414.12 / $1,960.17
| Professional | | $950.04 | $1,414.12 | $1,960.17 |
- 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
- $711.50 / $1,382.39 / $2,169.71
| Professional | | $711.50 | $1,382.39 | $2,169.71 |