- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.73 / $355.53 / $447.53
| Professional | | $349.73 | $355.53 | $447.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.20 / $2,767.20 / $2,767.20
| Facility | | $2,767.20 | $2,767.20 | $2,767.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.00 / $809.00 / $1,223.00
| Professional | | $674.00 | $809.00 | $1,223.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.62 / $686.42 / $983.76
| Professional | | $457.62 | $686.42 | $983.76 |
- 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
- $371.85 / $681.21 / $1,095.90
| Professional | | $371.85 | $681.21 | $1,095.90 |