- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.85 / $371.37 / $4,836.50
| Professional | | $282.85 | $371.37 | $4,836.50 |
- 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
- $569.00 / $861.00 / $1,343.00
| Professional | | $569.00 | $861.00 | $1,343.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.56 / $654.21 / $1,258.91
| Professional | | $391.56 | $654.21 | $1,258.91 |
- 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
- $508.06 / $930.57 / $1,459.89
| Professional | | $508.06 | $930.57 | $1,459.89 |