- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.06 / $354.55 / $561.04
| Professional | | $284.06 | $354.55 | $561.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.20 / $2,767.20 / $2,767.20
| Facility | | $2,767.20 | $2,767.20 | $2,767.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.00 / $797.00 / $1,206.00
| Professional | | $540.00 | $797.00 | $1,206.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.47 / $648.41 / $1,178.08
| Professional | | $416.47 | $648.41 | $1,178.08 |
- 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
- $596.82 / $810.56 / $1,456.01
| Professional | | $596.82 | $810.56 | $1,456.01 |