- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.12 / $322.80 / $6,171.00
| Professional | | $271.12 | $322.80 | $6,171.00 |
- 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
- $541.00 / $610.00 / $922.00
| Professional | | $541.00 | $610.00 | $922.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.34 / $586.69 / $1,197.79
| Professional | | $389.34 | $586.69 | $1,197.79 |
- 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
- $370.91 / $633.14 / $1,103.70
| Professional | | $370.91 | $633.14 | $1,103.70 |