- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.88 / $934.88 / $1,168.58
| Professional | | $934.88 | $934.88 | $1,168.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,172.45 / $9,172.45 / $9,172.45
| Facility | | $9,172.45 | $9,172.45 | $9,172.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.00 / $524.00 / $524.00
| Professional | | $524.00 | $524.00 | $524.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.23 / $1,136.52 / $3,577.26
| Facility | | $320.23 | $1,136.52 | $3,577.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.44 / $719.47 / $1,272.90
| Professional | | $336.44 | $719.47 | $1,272.90 |