- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.46 / $456.60 / $572.11
| Professional | | $454.46 | $456.60 | $572.11 |
- 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
- $940.00 / $1,128.00 / $1,816.00
| Professional | | $940.00 | $1,128.00 | $1,816.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.46 / $777.40 / $1,161.21
| Professional | | $515.46 | $777.40 | $1,161.21 |
- 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
- $409.26 / $798.85 / $1,381.50
| Professional | | $409.26 | $798.85 | $1,381.50 |