- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.50 / $543.78 / $651.51
| Professional | | $503.50 | $543.78 | $651.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $658.58 / $2,134.50 / $2,134.50
| Facility | | $658.58 | $2,134.50 | $2,134.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.00 / $2,166.00 / $2,166.00
| Professional | | $1,254.00 | $2,166.00 | $2,166.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.41 / $956.24 / $1,191.78
| Professional | | $810.41 | $956.24 | $1,191.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $475.00 / $593.75 / $593.75
| Facility | | $475.00 | $593.75 | $593.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.00 / $593.75 / $624.83
| Professional | | $570.00 | $593.75 | $624.83 |