- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.20 / $745.43 / $3,927.00
| Professional | | $577.20 | $745.43 | $3,927.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,006.39 / $5,006.39 / $5,006.39
| Facility | | $5,006.39 | $5,006.39 | $5,006.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.00 / $1,421.00 / $2,149.00
| Professional | | $1,101.00 | $1,421.00 | $2,149.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.84 / $1,240.35 / $2,091.17
| Professional | | $768.84 | $1,240.35 | $2,091.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.71 / $1,441.81 / $2,441.39
| Professional | | $806.71 | $1,441.81 | $2,441.39 |