- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $458.25 / $464.31 / $584.66
| Professional | | $458.25 | $464.31 | $584.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.20 / $2,767.20 / $2,767.20
| Facility | | $2,767.20 | $2,767.20 | $2,767.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.00 / $1,061.00 / $1,604.00
| Professional | | $884.00 | $1,061.00 | $1,604.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.95 / $916.42 / $1,285.23
| Professional | | $610.95 | $916.42 | $1,285.23 |
- 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
- $633.08 / $909.25 / $1,478.08
| Professional | | $633.08 | $909.25 | $1,478.08 |