- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.28 / $850.58 / $1,052.96
| Professional | | $836.28 | $850.58 | $1,052.96 |
- 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
- $1,745.00 / $2,094.00 / $3,370.00
| Professional | | $1,745.00 | $2,094.00 | $3,370.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.46 / $1,445.98 / $2,139.19
| Professional | | $898.46 | $1,445.98 | $2,139.19 |
- 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
- $729.22 / $1,498.14 / $2,602.77
| Professional | | $729.22 | $1,498.14 | $2,602.77 |