- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.62 / $974.52 / $2,725.52
| Professional | | $333.62 | $974.52 | $2,725.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.00 / $1,019.00 / $4,640.00
| Professional | | $753.00 | $1,019.00 | $4,640.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.24 / $1,181.10 / $4,355.55
| Professional | | $446.24 | $1,181.10 | $4,355.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.67 / $3,757.07 / $6,816.71
| Professional | | $1,946.67 | $3,757.07 | $6,816.71 |