- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.29 / $519.71 / $644.77
| Professional | | $505.29 | $519.71 | $644.77 |
- 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
- $1,047.00 / $1,256.00 / $2,023.00
| Professional | | $1,047.00 | $1,256.00 | $2,023.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.86 / $1,046.88 / $1,293.51
| Professional | | $655.86 | $1,046.88 | $1,293.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.28 / $1,004.26 / $1,843.41
| Professional | | $571.28 | $1,004.26 | $1,843.41 |