- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.02 / $428.18 / $537.61
| Professional | | $410.02 | $428.18 | $537.61 |
- 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
- $813.00 / $976.00 / $1,477.00
| Professional | | $813.00 | $976.00 | $1,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.83 / $856.37 / $1,178.75
| Professional | | $589.83 | $856.37 | $1,178.75 |
- 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
- $494.37 / $861.61 / $1,543.09
| Professional | | $494.37 | $861.61 | $1,543.09 |