- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.05 / $501.07 / $564.91
| Professional | | $393.05 | $501.07 | $564.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.80 / $2,428.80 / $2,428.80
| Facility | | $2,428.80 | $2,428.80 | $2,428.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $755.00 / $1,011.00 / $1,530.00
| Professional | | $755.00 | $1,011.00 | $1,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.21 / $860.83 / $1,484.45
| Professional | | $529.21 | $860.83 | $1,484.45 |
- 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
- $593.07 / $1,067.77 / $1,748.50
| Professional | | $593.07 | $1,067.77 | $1,748.50 |