- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.80 / $641.51 / $794.67
| Professional | | $621.80 | $641.51 | $794.67 |
- 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
- $1,292.00 / $1,550.00 / $2,495.00
| Professional | | $1,292.00 | $1,550.00 | $2,495.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.08 / $1,158.11 / $1,593.72
| Professional | | $772.08 | $1,158.11 | $1,593.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.97 / $1,278.11 / $2,067.00
| Professional | | $675.97 | $1,278.11 | $2,067.00 |