- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.44 / $576.62 / $724.84
| Professional | | $567.44 | $576.62 | $724.84 |
- 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
- $1,094.00 / $1,313.00 / $1,986.00
| Professional | | $1,094.00 | $1,313.00 | $1,986.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.17 / $1,095.26 / $1,594.36
| Professional | | $730.17 | $1,095.26 | $1,594.36 |
- 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
- $590.14 / $1,106.08 / $1,794.01
| Professional | | $590.14 | $1,106.08 | $1,794.01 |