- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.64 / $588.21 / $742.08
| Professional | | $582.64 | $588.21 | $742.08 |
- 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
- $1,121.00 / $1,345.00 / $2,034.00
| Professional | | $1,121.00 | $1,345.00 | $2,034.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.92 / $990.49 / $1,628.70
| Professional | | $657.92 | $990.49 | $1,628.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,200.82 / $4,200.00 / $14,634.00
| Facility | | $3,200.82 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.09 / $1,038.04 / $1,985.10
| Professional | | $804.09 | $1,038.04 | $1,985.10 |