- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.05 / $441.05 / $2,273.10
| Professional | | $441.05 | $441.05 | $2,273.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.00 / $2,518.00 / $10,092.00
| Professional | | $1,298.00 | $2,518.00 | $10,092.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.22 / $780.33 / $4,078.21
| Professional | | $520.22 | $780.33 | $4,078.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,836.04 / $4,698.08 / $7,783.09
| Professional | | $2,836.04 | $4,698.08 | $7,783.09 |