- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $565.67 / $592.86 / $3,404.25
| Professional | | $565.67 | $592.86 | $3,404.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.20 / $2,767.20 / $2,767.20
| Facility | | $2,767.20 | $2,767.20 | $2,767.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.00 / $1,302.00 / $1,970.00
| Professional | | $1,085.00 | $1,302.00 | $1,970.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.85 / $1,081.28 / $1,576.04
| Professional | | $720.85 | $1,081.28 | $1,576.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.60 / $1,111.66 / $1,745.89
| Professional | | $583.60 | $1,111.66 | $1,745.89 |