- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.53 / $544.66 / $605.41
| Professional | | $428.53 | $544.66 | $605.41 |
- 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
- $826.00 / $1,121.00 / $1,696.00
| Professional | | $826.00 | $1,121.00 | $1,696.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.92 / $938.56 / $1,655.56
| Professional | | $577.92 | $938.56 | $1,655.56 |
- 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
- $616.75 / $1,179.92 / $1,908.38
| Professional | | $616.75 | $1,179.92 | $1,908.38 |