- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.62 / $554.60 / $2,578.76
| Professional | | $322.62 | $554.60 | $2,578.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.19 / $640.65 / $1,261.40
| Facility | | $157.19 | $640.65 | $1,261.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.00 / $716.00 / $716.00
| Professional | | $716.00 | $716.00 | $716.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.40 / $401.20 / $1,047.09
| Professional | | $383.40 | $401.20 | $1,047.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $409.50 / $4,085.55 / $12,000.00
| Facility | | $409.50 | $4,085.55 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.00 / $3,174.88 / $3,174.88
| Professional | | $952.00 | $3,174.88 | $3,174.88 |