- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.11 / $656.39 / $12,462.68
| Professional | | $525.11 | $656.39 | $12,462.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $427.54 / $691.84 / $764.26
| Facility | | $427.54 | $691.84 | $764.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.55 / $1,187.55 / $17,449.43
| Professional | | $1,187.55 | $1,187.55 | $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 / $5,393.75 / $9,157.12
| Professional | | $475.00 | $5,393.75 | $9,157.12 |