- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.72 / $263.45 / $338.95
| Professional | | $262.72 | $263.45 | $338.95 |
- 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
- $503.00 / $604.00 / $912.00
| Professional | | $503.00 | $604.00 | $912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.44 / $525.42 / $735.86
| Professional | | $353.44 | $525.42 | $735.86 |
- 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
- $294.80 / $516.12 / $871.00
| Professional | | $294.80 | $516.12 | $871.00 |