- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.31 / $462.48 / $584.19
| Professional | | $457.31 | $462.48 | $584.19 |
- 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
- $880.00 / $1,056.00 / $1,597.00
| Professional | | $880.00 | $1,056.00 | $1,597.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.04 / $914.62 / $1,281.17
| Professional | | $614.04 | $914.62 | $1,281.17 |
- 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
- $633.57 / $900.62 / $1,544.40
| Professional | | $633.57 | $900.62 | $1,544.40 |