- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.22 / $509.17 / $634.58
| Professional | | $503.22 | $509.17 | $634.58 |
- 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
- $1,045.00 / $1,254.00 / $2,018.00
| Professional | | $1,045.00 | $1,254.00 | $2,018.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.19 / $1,018.35 / $1,287.96
| Professional | | $620.19 | $1,018.35 | $1,287.96 |
- 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
- $659.68 / $994.64 / $1,546.08
| Professional | | $659.68 | $994.64 | $1,546.08 |