- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.01 / $386.72 / $466.29
| Professional | | $307.01 | $386.72 | $466.29 |
- 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
- $591.00 / $865.00 / $1,308.00
| Professional | | $591.00 | $865.00 | $1,308.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.09 / $671.83 / $1,276.83
| Professional | | $408.09 | $671.83 | $1,276.83 |
- 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
- $493.62 / $906.19 / $1,446.91
| Professional | | $493.62 | $906.19 | $1,446.91 |