- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.82 / $414.56 / $677.42
| Professional | | $319.82 | $414.56 | $677.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,385.60 / $1,385.60 / $1,385.60
| Facility | | $1,385.60 | $1,385.60 | $1,385.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.00 / $929.00 / $1,461.00
| Professional | | $614.00 | $929.00 | $1,461.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.88 / $726.33 / $1,344.47
| Professional | | $426.88 | $726.33 | $1,344.47 |
- 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
- $504.02 / $970.96 / $1,509.27
| Professional | | $504.02 | $970.96 | $1,509.27 |