- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.67 / $737.81 / $1,544.49
| Professional | | $392.67 | $737.81 | $1,544.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.75 / $378.06 / $666.62
| Facility | | $252.75 | $378.06 | $666.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,460.17 / $1,460.17
| Professional | | $1,350.00 | $1,460.17 | $1,460.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $487.00 / $487.00 / $487.00
| Facility | | $487.00 | $487.00 | $487.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.53 / $445.00 / $685.57
| Professional | | $372.53 | $445.00 | $685.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $372.00 / $948.20
| Professional | | $5.00 | $372.00 | $948.20 |