- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.09 / $734.51 / $2,611.00
| Professional | | $525.09 | $734.51 | $2,611.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,164.90 / $4,924.78 / $11,221.82
| Facility | | $2,164.90 | $4,924.78 | $11,221.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.95 / $812.12 / $2,315.25
| Professional | | $688.95 | $812.12 | $2,315.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.85 / $1,112.83 / $2,315.25
| Professional | | $558.85 | $1,112.83 | $2,315.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.84 / $1,112.83 / $2,315.25
| Professional | | $833.84 | $1,112.83 | $2,315.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.51 / $914.54 / $2,841.71
| Professional | | $513.51 | $914.54 | $2,841.71 |