- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.58 / $505.69 / $650.94
| Professional | | $457.58 | $505.69 | $650.94 |
- 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
- $885.00 / $978.00 / $1,480.00
| Professional | | $885.00 | $978.00 | $1,480.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.79 / $915.17 / $1,435.16
| Professional | | $589.79 | $915.17 | $1,435.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.52 / $967.47 / $1,503.84
| Professional | | $514.52 | $967.47 | $1,503.84 |