- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.33 / $275.14 / $673.77
| Professional | | $257.33 | $275.14 | $673.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,753.00 / $8,753.00 / $8,753.00
| Professional | | $8,753.00 | $8,753.00 | $8,753.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,652.37 / $2,652.37 / $2,652.37
| Facility | | $2,652.37 | $2,652.37 | $2,652.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.73 / $338.92 / $1,172.77
| Professional | | $262.73 | $338.92 | $1,172.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.66 / $833.89 / $1,353.19
| Professional | | $586.66 | $833.89 | $1,353.19 |