- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,439.18 / $1,439.18 / $6,496.10
| Professional | | $1,439.18 | $1,439.18 | $6,496.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $557.00 / $668.00 / $836.00
| Professional | | $557.00 | $668.00 | $836.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.47 / $477.22 / $677.53
| Professional | | $392.47 | $477.22 | $677.53 |
- 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
- $459.25 / $732.05 / $1,129.91
| Professional | | $459.25 | $732.05 | $1,129.91 |