- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $407.38 / $707.95
| Professional | | $380.19 | $407.38 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,202.26 / $1,445.44
| Professional | | $794.33 | $1,202.26 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $758.58 / $1,148.15
| Professional | | $512.86 | $758.58 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $10,471.29
| Facility | | $2,630.27 | $2,754.23 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $724.44 / $1,659.59
| Professional | | $457.09 | $724.44 | $1,659.59 |