- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.67 / $388.15 / $472.15
| Professional | | $306.67 | $388.15 | $472.15 |
- 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
- $597.00 / $886.00 / $1,341.00
| Professional | | $597.00 | $886.00 | $1,341.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.72 / $671.05 / $1,310.00
| Professional | | $413.72 | $671.05 | $1,310.00 |
- 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
- $505.79 / $918.02 / $1,459.89
| Professional | | $505.79 | $918.02 | $1,459.89 |