- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.10 / $314.83 / $493.22
| Professional | | $249.10 | $314.83 | $493.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.80 / $2,428.80 / $2,428.80
| Facility | | $2,428.80 | $2,428.80 | $2,428.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.00 / $720.00 / $1,348.00
| Professional | | $476.00 | $720.00 | $1,348.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.45 / $643.51 / $1,101.58
| Professional | | $340.45 | $643.51 | $1,101.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.65 / $947.28 / $1,539.22
| Professional | | $555.65 | $947.28 | $1,539.22 |