- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.68 / $392.25 / $520.83
| Professional | | $310.68 | $392.25 | $520.83 |
- 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
- $595.00 / $900.00 / $1,419.00
| Professional | | $595.00 | $900.00 | $1,419.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $419.38 / $705.17 / $1,305.64
| Professional | | $419.38 | $705.17 | $1,305.64 |
- 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
- $543.80 / $943.79 / $1,467.03
| Professional | | $543.80 | $943.79 | $1,467.03 |