- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.80 / $517.28 / $846.43
| Professional | | $404.80 | $517.28 | $846.43 |
- 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
- $780.00 / $1,180.00 / $1,799.00
| Professional | | $780.00 | $1,180.00 | $1,799.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.37 / $860.50 / $1,712.89
| Professional | | $394.37 | $860.50 | $1,712.89 |
- 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
- $665.76 / $1,232.17 / $1,915.29
| Professional | | $665.76 | $1,232.17 | $1,915.29 |