- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.71 / $1,802.00 / $7,704.50
| Professional | | $409.71 | $1,802.00 | $7,704.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.80 / $2,428.80 / $2,428.80
| Facility | | $2,428.80 | $2,428.80 | $2,428.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.00 / $944.00 / $1,428.00
| Professional | | $787.00 | $944.00 | $1,428.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.33 / $823.97 / $1,134.76
| Professional | | $554.33 | $823.97 | $1,134.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $5,724.10 / $10,877.00
| Facility | | $2,607.00 | $5,724.10 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.60 / $817.03 / $1,428.69
| Professional | | $520.60 | $817.03 | $1,428.69 |