- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.55 / $382.15 / $454.61
| Professional | | $329.55 | $382.15 | $454.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,021.18 / $7,021.18 / $7,021.18
| Facility | | $7,021.18 | $7,021.18 | $7,021.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.89 / $463.39 / $787.96
| Professional | | $363.89 | $463.39 | $787.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,677.00 / $3,677.00 / $3,677.00
| Facility | | $3,677.00 | $3,677.00 | $3,677.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.26 / $473.62 / $909.18
| Professional | | $356.26 | $473.62 | $909.18 |