- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.29 / $426.48 / $535.12
| Professional | | $424.29 | $426.48 | $535.12 |
- 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
- $815.00 / $978.00 / $1,480.00
| Professional | | $815.00 | $978.00 | $1,480.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.53 / $852.96 / $1,174.21
| Professional | | $573.53 | $852.96 | $1,174.21 |
- 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
- $536.22 / $846.29 / $1,471.59
| Professional | | $536.22 | $846.29 | $1,471.59 |