- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.66 / $516.51 / $645.50
| Professional | | $512.66 | $516.51 | $645.50 |
- 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
- $1,061.00 / $1,273.00 / $2,048.00
| Professional | | $1,061.00 | $1,273.00 | $2,048.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.86 / $1,033.32 / $1,310.20
| Professional | | $629.86 | $1,033.32 | $1,310.20 |
- 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
- $470.38 / $1,003.70 / $1,560.15
| Professional | | $470.38 | $1,003.70 | $1,560.15 |