- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.21 / $5,441.52 / $5,441.52
| Professional | | $973.21 | $5,441.52 | $5,441.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.00 / $1,134.00 / $1,134.00
| Professional | | $1,134.00 | $1,134.00 | $1,134.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.08 / $1,438.66 / $4,823.74
| Facility | | $1,227.08 | $1,438.66 | $4,823.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.43 / $1,227.08 / $1,227.08
| Professional | | $399.43 | $1,227.08 | $1,227.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.08 / $1,438.66 / $4,823.74
| Facility | | $1,227.08 | $1,438.66 | $4,823.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.64 / $761.64 / $1,227.08
| Professional | | $761.64 | $761.64 | $1,227.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.43 / $355.43 / $846.27
| Professional | | $355.43 | $355.43 | $846.27 |