- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.49 / $373.89 / $711.68
| Professional | | $253.49 | $373.89 | $711.68 |
- 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
- $492.00 / $722.00 / $1,093.00
| Professional | | $492.00 | $722.00 | $1,093.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.28 / $807.39 / $1,597.58
| Professional | | $527.28 | $807.39 | $1,597.58 |
- 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
- $775.59 / $1,405.60 / $2,280.19
| Professional | | $775.59 | $1,405.60 | $2,280.19 |