- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $338.84 / $602.56
| Professional | | $302.00 | $338.84 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $954.99 / $1,148.15
| Professional | | $645.65 | $954.99 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $602.56 / $933.25
| Professional | | $426.58 | $602.56 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $10,471.29
| Facility | | $2,630.27 | $2,754.23 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $588.84 / $1,288.25
| Professional | | $354.81 | $588.84 | $1,288.25 |