- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.75 / $513.79 / $711.19
| Professional | | $405.75 | $513.79 | $711.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,385.60 / $1,385.60 / $1,385.60
| Facility | | $1,385.60 | $1,385.60 | $1,385.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.00 / $1,032.00 / $1,561.00
| Professional | | $777.00 | $1,032.00 | $1,561.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.46 / $885.64 / $1,514.33
| Professional | | $544.46 | $885.64 | $1,514.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.80 / $1,057.33 / $1,714.69
| Professional | | $624.80 | $1,057.33 | $1,714.69 |