- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.99 / $577.64 / $733.27
| Professional | | $528.99 | $577.64 | $733.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.60 / $1,373.60 / $1,373.60
| Facility | | $1,373.60 | $1,373.60 | $1,373.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.00 / $1,103.00 / $1,668.00
| Professional | | $1,004.00 | $1,103.00 | $1,668.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.65 / $1,041.15 / $1,612.31
| Professional | | $683.65 | $1,041.15 | $1,612.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.34 / $1,106.78 / $1,753.71
| Professional | | $597.34 | $1,106.78 | $1,753.71 |