- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.56 / $411.94 / $566.10
| Professional | | $331.56 | $411.94 | $566.10 |
- 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
- $669.00 / $1,012.00 / $1,581.00
| Professional | | $669.00 | $1,012.00 | $1,581.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.60 / $743.22 / $1,392.24
| Professional | | $438.60 | $743.22 | $1,392.24 |
- 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
- $525.33 / $1,009.27 / $1,596.40
| Professional | | $525.33 | $1,009.27 | $1,596.40 |