- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $667.85 / $667.85 / $740.46
| Professional | | $667.85 | $667.85 | $740.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.25 / $609.91 / $609.91
| Professional | | $508.25 | $609.91 | $609.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,121.17 / $4,313.91 / $5,844.26
| Facility | | $2,121.17 | $4,313.91 | $5,844.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $778.68 / $1,486.61 / $2,769.36
| Professional | | $778.68 | $1,486.61 | $2,769.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.08 / $841.99 / $2,385.94
| Professional | | $519.08 | $841.99 | $2,385.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |