- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.58 / $334.22 / $498.56
| Professional | | $267.58 | $334.22 | $498.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,385.60 / $1,385.60 / $1,385.60
| Facility | | $1,385.60 | $1,385.60 | $1,385.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.00 / $722.00 / $1,092.00
| Professional | | $505.00 | $722.00 | $1,092.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.28 / $567.09 / $1,065.99
| Professional | | $350.28 | $567.09 | $1,065.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.70 / $641.71 / $1,120.58
| Professional | | $401.70 | $641.71 | $1,120.58 |