- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.65 / $501.59 / $633.32
| Professional | | $492.65 | $501.59 | $633.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.00 / $252.00 / $252.00
| Facility | | $252.00 | $252.00 | $252.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.00 / $958.00 / $1,450.00
| Professional | | $941.00 | $958.00 | $1,450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.55 / $966.32 / $1,395.79
| Professional | | $639.55 | $966.32 | $1,395.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.07 / $967.47 / $1,571.69
| Professional | | $530.07 | $967.47 | $1,571.69 |