- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.00 / $428.31 / $542.64
| Professional | | $428.00 | $428.31 | $542.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.60 / $1,373.60 / $1,373.60
| Facility | | $1,373.60 | $1,373.60 | $1,373.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.00 / $997.00 / $1,510.00
| Professional | | $831.00 | $997.00 | $1,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.03 / $844.54 / $1,207.48
| Professional | | $563.03 | $844.54 | $1,207.48 |
- 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
- $549.02 / $833.74 / $1,465.11
| Professional | | $549.02 | $833.74 | $1,465.11 |