- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.55 / $369.06 / $4,834.80
| Professional | | $249.55 | $369.06 | $4,834.80 |
- 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
- $486.00 / $735.00 / $1,136.00
| Professional | | $486.00 | $735.00 | $1,136.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.23 / $553.37 / $1,073.95
| Professional | | $335.23 | $553.37 | $1,073.95 |
- 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
- $554.66 / $796.63 / $1,251.91
| Professional | | $554.66 | $796.63 | $1,251.91 |