- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.56 / $308.89 / $391.74
| Professional | | $242.56 | $308.89 | $391.74 |
- 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
- $467.00 / $707.00 / $1,093.00
| Professional | | $467.00 | $707.00 | $1,093.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.63 / $539.12 / $1,035.80
| Professional | | $328.63 | $539.12 | $1,035.80 |
- 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
- $543.89 / $665.99 / $1,238.90
| Professional | | $543.89 | $665.99 | $1,238.90 |