- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.46 / $239.41 / $2,771.00
| Professional | | $201.46 | $239.41 | $2,771.00 |
- 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
- $404.00 / $453.00 / $685.00
| Professional | | $404.00 | $453.00 | $685.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.45 / $423.69 / $895.28
| Professional | | $282.45 | $423.69 | $895.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $3,200.82 / $10,877.00
| Facility | | $2,607.00 | $3,200.82 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.48 / $465.98 / $777.40
| Professional | | $261.48 | $465.98 | $777.40 |