- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.59 / $319.70 / $396.65
| Professional | | $252.59 | $319.70 | $396.65 |
- 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
- $486.00 / $733.00 / $1,109.00
| Professional | | $486.00 | $733.00 | $1,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.33 / $559.17 / $1,077.31
| Professional | | $344.33 | $559.17 | $1,077.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $3,200.82 / $10,877.00
| Facility | | $2,607.00 | $3,200.82 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $433.20 / $783.60 / $1,263.58
| Professional | | $433.20 | $783.60 | $1,263.58 |