- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.23 / $536.52 / $677.89
| Professional | | $533.23 | $536.52 | $677.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.40 / $1,650.40 / $1,650.40
| Facility | | $1,650.40 | $1,650.40 | $1,650.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.00 / $1,226.00 / $1,855.00
| Professional | | $1,022.00 | $1,226.00 | $1,855.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.27 / $1,050.40 / $1,486.74
| Professional | | $700.27 | $1,050.40 | $1,486.74 |
- 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
- $560.86 / $1,039.92 / $1,658.80
| Professional | | $560.86 | $1,039.92 | $1,658.80 |