- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.23 / $423.92 / $571.94
| Professional | | $335.23 | $423.92 | $571.94 |
- 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
- $642.00 / $971.00 / $1,547.00
| Professional | | $642.00 | $971.00 | $1,547.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.84 / $769.91 / $1,404.90
| Professional | | $447.84 | $769.91 | $1,404.90 |
- 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
- $659.62 / $1,036.43 / $1,611.03
| Professional | | $659.62 | $1,036.43 | $1,611.03 |