- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.62 / $729.91 / $909.42
| Professional | | $723.62 | $729.91 | $909.42 |
- 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
- $1,389.00 / $1,667.00 / $2,521.00
| Professional | | $1,389.00 | $1,667.00 | $2,521.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.25 / $1,459.82 / $2,014.35
| Professional | | $1,017.25 | $1,459.82 | $2,014.35 |
- 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
- $834.86 / $1,480.12 / $2,675.38
| Professional | | $834.86 | $1,480.12 | $2,675.38 |