- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.87 / $801.98 / $3,988.02
| Professional | | $578.87 | $801.98 | $3,988.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.64 / $3,100.49 / $3,655.78
| Facility | | $292.64 | $3,100.49 | $3,655.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,728.85 / $8,197.86 / $8,197.86
| Professional | | $2,728.85 | $8,197.86 | $8,197.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,275.00 / $3,275.00 / $3,275.00
| Facility | | $3,275.00 | $3,275.00 | $3,275.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.61 / $2,064.00 / $3,015.00
| Professional | | $1,648.61 | $2,064.00 | $3,015.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.97 / $2,355.61 / $2,394.98
| Professional | | $1,741.97 | $2,355.61 | $2,394.98 |