- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.82 / $379.42 / $439.11
| Professional | | $335.82 | $379.42 | $439.11 |
- 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
- $651.00 / $735.00 / $1,112.00
| Professional | | $651.00 | $735.00 | $1,112.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.26 / $658.32 / $1,078.75
| Professional | | $394.26 | $658.32 | $1,078.75 |
- 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
- $490.42 / $728.58 / $1,132.50
| Professional | | $490.42 | $728.58 | $1,132.50 |