- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.40 / $636.37 / $971.13
| Professional | | $583.40 | $636.37 | $971.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,470.44 / $13,470.44 / $17,251.66
| Facility | | $13,470.44 | $13,470.44 | $17,251.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.64 / $1,200.89 / $1,992.06
| Professional | | $824.64 | $1,200.89 | $1,992.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.64 / $1,065.92 / $1,992.06
| Professional | | $824.64 | $1,065.92 | $1,992.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.91 / $872.14 / $2,445.03
| Professional | | $649.91 | $872.14 | $2,445.03 |