- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.24 / $388.07 / $500.83
| Professional | | $347.24 | $388.07 | $500.83 |
- 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
- $673.00 / $751.00 / $1,136.00
| Professional | | $673.00 | $751.00 | $1,136.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.28 / $694.47 / $1,449.76
| Professional | | $445.28 | $694.47 | $1,449.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.86 / $741.10 / $1,151.97
| Professional | | $397.86 | $741.10 | $1,151.97 |