- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.11 / $7,248.22 / $12,462.68
| Professional | | $525.11 | $7,248.22 | $12,462.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $692.84 / $692.84
| Professional | | $150.00 | $692.84 | $692.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $392.80 / $502.33 / $878.54
| Facility | | $392.80 | $502.33 | $878.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.70 / $9,157.12 / $17,449.43
| Professional | | $501.70 | $9,157.12 | $17,449.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $513.00 / $513.00 / $513.00
| Facility | | $513.00 | $513.00 | $513.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.00 / $513.00 / $9,157.12
| Professional | | $475.00 | $513.00 | $9,157.12 |