- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.52 / $423.76 / $472.07
| Professional | | $325.52 | $423.76 | $472.07 |
- 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
- $626.00 / $866.00 / $1,311.00
| Professional | | $626.00 | $866.00 | $1,311.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.81 / $738.28 / $1,273.78
| Professional | | $466.81 | $738.28 | $1,273.78 |
- 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
- $538.84 / $951.45 / $1,526.21
| Professional | | $538.84 | $951.45 | $1,526.21 |