- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.60 / $471.50 / $586.94
| Professional | | $467.60 | $471.50 | $586.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.80 / $2,428.80 / $2,428.80
| Facility | | $2,428.80 | $2,428.80 | $2,428.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.00 / $1,094.00 / $1,656.00
| Professional | | $912.00 | $1,094.00 | $1,656.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.28 / $935.19 / $1,322.40
| Professional | | $643.28 | $935.19 | $1,322.40 |
- 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
- $745.35 / $936.68 / $1,730.30
| Professional | | $745.35 | $936.68 | $1,730.30 |