- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.52 / $591.91 / $748.53
| Professional | | $590.52 | $591.91 | $748.53 |
- 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
- $1,132.00 / $1,358.00 / $2,056.00
| Professional | | $1,132.00 | $1,358.00 | $2,056.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.02 / $1,181.04 / $1,639.69
| Professional | | $802.02 | $1,181.04 | $1,639.69 |
- 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
- $631.57 / $1,168.77 / $1,878.49
| Professional | | $631.57 | $1,168.77 | $1,878.49 |