- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.58 / $705.39 / $887.61
| Professional | | $700.58 | $705.39 | $887.61 |
- 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
- $1,345.00 / $1,614.00 / $2,441.00
| Professional | | $1,345.00 | $1,614.00 | $2,441.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.48 / $1,401.15 / $1,950.35
| Professional | | $938.48 | $1,401.15 | $1,950.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.83 / $1,291.55 / $2,299.69
| Professional | | $736.83 | $1,291.55 | $2,299.69 |