- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.53 / $560.48 / $3,352.85
| Professional | | $389.53 | $560.48 | $3,352.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.00 / $1,522.00 / $3,668.00
| Professional | | $984.00 | $1,522.00 | $3,668.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.82 / $915.71 / $4,159.39
| Professional | | $504.82 | $915.71 | $4,159.39 |
- 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
- $1,139.04 / $2,936.25 / $10,307.68
| Professional | | $1,139.04 | $2,936.25 | $10,307.68 |