- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $471.86 / $472.96 / $592.62
| Professional | | $471.86 | $472.96 | $592.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.60 / $1,373.60 / $1,373.60
| Facility | | $1,373.60 | $1,373.60 | $1,373.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.00 / $1,084.00 / $1,639.00
| Professional | | $903.00 | $1,084.00 | $1,639.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.06 / $943.72 / $1,315.18
| Professional | | $658.06 | $943.72 | $1,315.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $3,200.82 / $10,877.00
| Facility | | $2,607.00 | $3,200.82 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.36 / $845.68 / $1,670.51
| Professional | | $668.36 | $845.68 | $1,670.51 |