- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $812.83 / $977.24
| Professional | | $562.34 | $812.83 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,047.13 / $3,311.31
| Professional | | $831.76 | $1,047.13 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,000.00 / $3,467.37
| Professional | | $676.08 | $1,000.00 | $3,467.37 |