- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.40 / $149.12 / $166.06
| Professional | | $130.40 | $149.12 | $166.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.60 / $1,373.60 / $1,373.60
| Facility | | $1,373.60 | $1,373.60 | $1,373.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.00 / $301.00 / $456.00
| Professional | | $251.00 | $301.00 | $456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.35 / $260.79 / $361.09
| Professional | | $179.35 | $260.79 | $361.09 |
- 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
- $143.53 / $233.13 / $407.10
| Professional | | $143.53 | $233.13 | $407.10 |