- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.66 / $577.49 / $731.11
| Professional | | $575.66 | $577.49 | $731.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.40 / $1,650.40 / $1,650.40
| Facility | | $1,650.40 | $1,650.40 | $1,650.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.00 / $1,324.00 / $2,002.00
| Professional | | $1,103.00 | $1,324.00 | $2,002.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $698.92 / $1,048.38 / $1,601.53
| Professional | | $698.92 | $1,048.38 | $1,601.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $3,905.54 / $5,606.00
| Facility | | $1,275.00 | $3,905.54 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.22 / $1,126.98 / $1,805.68
| Professional | | $596.22 | $1,126.98 | $1,805.68 |