- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.12 / $511.87 / $3,344.40
| Professional | | $493.12 | $511.87 | $3,344.40 |
- 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
- $947.00 / $1,136.00 / $1,720.00
| Professional | | $947.00 | $1,136.00 | $1,720.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.01 / $970.52 / $1,384.36
| Professional | | $647.01 | $970.52 | $1,384.36 |
- 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
- $674.72 / $969.05 / $1,575.60
| Professional | | $674.72 | $969.05 | $1,575.60 |