- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $794.33 / $3,311.31
| Professional | | $467.74 | $794.33 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Professional | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $933.25
| Facility | | $741.31 | $741.31 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $933.25
| Professional | | $741.31 | $741.31 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $758.58 / $1,288.25
| Professional | | $79.43 | $758.58 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,258.93 / $1,949.84
| Professional | | $1,023.29 | $1,258.93 | $1,949.84 |