- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.73 / $570.78 / $735.73
| Professional | | $558.73 | $570.78 | $735.73 |
- 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
- $1,172.00 / $1,406.00 / $2,264.00
| Professional | | $1,172.00 | $1,406.00 | $2,264.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.45 / $1,162.73 / $1,470.67
| Professional | | $720.45 | $1,162.73 | $1,470.67 |
- 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
- $637.26 / $1,162.52 / $1,807.02
| Professional | | $637.26 | $1,162.52 | $1,807.02 |