- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.34 / $422.84 / $541.22
| Professional | | $395.34 | $422.84 | $541.22 |
- 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
- $755.00 / $818.00 / $1,237.00
| Professional | | $755.00 | $818.00 | $1,237.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.63 / $780.61 / $1,197.80
| Professional | | $508.63 | $780.61 | $1,197.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.33 / $812.14 / $1,272.71
| Professional | | $571.33 | $812.14 | $1,272.71 |