- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.59 / $318.83 / $504.24
| Professional | | $249.59 | $318.83 | $504.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.00 / $1,304.00 / $1,304.00
| Facility | | $1,304.00 | $1,304.00 | $1,304.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.00 / $696.00 / $1,106.00
| Professional | | $460.00 | $696.00 | $1,106.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.54 / $554.20 / $1,017.44
| Professional | | $347.54 | $554.20 | $1,017.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.09 / $760.61 / $1,245.39
| Professional | | $424.09 | $760.61 | $1,245.39 |