- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.28 / $516.72 / $750.53
| Professional | | $412.28 | $516.72 | $750.53 |
- 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
- $787.00 / $1,087.00 / $1,644.00
| Professional | | $787.00 | $1,087.00 | $1,644.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $557.49 / $914.38 / $1,600.02
| Professional | | $557.49 | $914.38 | $1,600.02 |
- 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
- $811.92 / $1,154.14 / $1,966.91
| Professional | | $811.92 | $1,154.14 | $1,966.91 |