- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.72 / $606.70 / $727.80
| Professional | | $575.72 | $606.70 | $727.80 |
- 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
- $1,155.00 / $1,386.00 / $2,096.00
| Professional | | $1,155.00 | $1,386.00 | $2,096.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $739.57 / $1,109.35 / $1,680.32
| Professional | | $739.57 | $1,109.35 | $1,680.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.87 / $1,113.75 / $1,844.71
| Professional | | $623.87 | $1,113.75 | $1,844.71 |