- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.50 / $641.32 / $1,071.56
| Professional | | $460.50 | $641.32 | $1,071.56 |
- 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
- $877.00 / $1,327.00 / $2,121.00
| Professional | | $877.00 | $1,327.00 | $2,121.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.59 / $969.90 / $1,644.14
| Professional | | $459.59 | $969.90 | $1,644.14 |
- 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
- $702.50 / $1,247.44 / $2,178.36
| Professional | | $702.50 | $1,247.44 | $2,178.36 |