- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.36 / $474.23 / $5,013.14
| Professional | | $456.36 | $474.23 | $5,013.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.60 / $1,373.60 / $1,373.60
| Facility | | $1,373.60 | $1,373.60 | $1,373.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.00 / $1,056.00 / $1,597.00
| Professional | | $880.00 | $1,056.00 | $1,597.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.47 / $894.70 / $1,283.89
| Professional | | $596.47 | $894.70 | $1,283.89 |
- 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
- $495.49 / $890.17 / $1,459.89
| Professional | | $495.49 | $890.17 | $1,459.89 |