- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.89 / $383.48 / $4,629.10
| Professional | | $261.89 | $383.48 | $4,629.10 |
- 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
- $505.00 / $735.00 / $1,112.00
| Professional | | $505.00 | $735.00 | $1,112.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.13 / $579.37 / $1,085.26
| Professional | | $354.13 | $579.37 | $1,085.26 |
- 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
- $438.14 / $789.18 / $1,226.70
| Professional | | $438.14 | $789.18 | $1,226.70 |