- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.16 / $172.49 / $181.35
| Professional | | $133.16 | $172.49 | $181.35 |
- 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
- $253.00 / $333.00 / $503.00
| Professional | | $253.00 | $333.00 | $503.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.84 / $293.13 / $489.77
| Professional | | $174.84 | $293.13 | $489.77 |
- 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
- $246.96 / $351.05 / $572.00
| Professional | | $246.96 | $351.05 | $572.00 |