- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.81 / $381.90 / $480.49
| Professional | | $376.81 | $381.90 | $480.49 |
- 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
- $725.00 / $870.00 / $1,315.00
| Professional | | $725.00 | $870.00 | $1,315.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.69 / $742.03 / $1,056.82
| Professional | | $494.69 | $742.03 | $1,056.82 |
- 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
- $474.65 / $702.79 / $1,249.30
| Professional | | $474.65 | $702.79 | $1,249.30 |