- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.53 / $343.63 / $433.44
| Professional | | $343.53 | $343.63 | $433.44 |
- 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
- $657.00 / $788.00 / $1,193.00
| Professional | | $657.00 | $788.00 | $1,193.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.82 / $687.06 / $953.06
| Professional | | $459.82 | $687.06 | $953.06 |
- 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
- $431.54 / $677.02 / $1,184.29
| Professional | | $431.54 | $677.02 | $1,184.29 |