- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.92 / $334.47 / $1,704.25
| Professional | | $322.92 | $334.47 | $1,704.25 |
- 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
- $623.00 / $748.00 / $1,132.00
| Professional | | $623.00 | $748.00 | $1,132.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $419.06 / $628.60 / $912.40
| Professional | | $419.06 | $628.60 | $912.40 |
- 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
- $347.70 / $626.88 / $1,012.70
| Professional | | $347.70 | $626.88 | $1,012.70 |