- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $532.50 / $665.63 / $1,938.30
| Facility | | $532.50 | $665.63 | $1,938.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.50 / $532.50 / $603.50
| Professional | | $532.50 | $532.50 | $603.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.20 / $937.20 / $1,398.70
| Professional | | $369.20 | $937.20 | $1,398.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,235.40 / $3,372.50 / $3,372.50
| Facility | | $1,235.40 | $3,372.50 | $3,372.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,535.80 / $3,535.80 / $5,325.00
| Professional | | $3,535.80 | $3,535.80 | $5,325.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.20 / $426.00 / $710.00
| Professional | | $298.20 | $426.00 | $710.00 |