- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.26 / $437.82 / $581.00
| Professional | | $312.26 | $437.82 | $581.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,385.60 / $1,385.60 / $1,385.60
| Facility | | $1,385.60 | $1,385.60 | $1,385.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.00 / $838.00 / $1,267.00
| Professional | | $596.00 | $838.00 | $1,267.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.71 / $673.46 / $1,230.48
| Professional | | $416.71 | $673.46 | $1,230.48 |
- 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
- $461.56 / $854.64 / $1,363.71
| Professional | | $461.56 | $854.64 | $1,363.71 |