- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.56 / $461.50 / $541.16
| Professional | | $364.56 | $461.50 | $541.16 |
- 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
- $697.00 / $994.00 / $1,504.00
| Professional | | $697.00 | $994.00 | $1,504.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.00 / $797.67 / $1,466.64
| Professional | | $481.00 | $797.67 | $1,466.64 |
- 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
- $568.48 / $1,049.67 / $1,656.20
| Professional | | $568.48 | $1,049.67 | $1,656.20 |