- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.54 / $378.37 / $467.21
| Professional | | $361.54 | $378.37 | $467.21 |
- 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
- $706.00 / $847.00 / $1,280.00
| Professional | | $706.00 | $847.00 | $1,280.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.30 / $669.45 / $1,042.39
| Professional | | $446.30 | $669.45 | $1,042.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.38 / $681.91 / $1,059.96
| Professional | | $361.38 | $681.91 | $1,059.96 |