- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.04 / $758.72 / $920.91
| Professional | | $716.04 | $758.72 | $920.91 |
- 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
- $1,559.00 / $1,871.00 / $3,012.00
| Professional | | $1,559.00 | $1,871.00 | $3,012.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.41 / $1,473.32 / $1,947.12
| Professional | | $911.41 | $1,473.32 | $1,947.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $3,905.54 / $10,877.00
| Facility | | $2,607.00 | $3,905.54 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.64 / $1,465.51 / $2,562.28
| Professional | | $813.64 | $1,465.51 | $2,562.28 |