- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.60 / $510.74 / $641.08
| Professional | | $503.60 | $510.74 | $641.08 |
- 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
- $972.00 / $1,166.00 / $1,764.00
| Professional | | $972.00 | $1,166.00 | $1,764.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.65 / $980.48 / $1,416.65
| Professional | | $653.65 | $980.48 | $1,416.65 |
- 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
- $519.64 / $975.13 / $1,558.71
| Professional | | $519.64 | $975.13 | $1,558.71 |