- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.02 / $591.87 / $730.50
| Professional | | $558.02 | $591.87 | $730.50 |
- 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
- $1,214.00 / $1,457.00 / $2,346.00
| Professional | | $1,214.00 | $1,457.00 | $2,346.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $721.32 / $1,163.39 / $1,526.91
| Professional | | $721.32 | $1,163.39 | $1,526.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.44 / $1,167.38 / $1,891.50
| Professional | | $631.44 | $1,167.38 | $1,891.50 |