- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.16 / $502.87 / $3,174.90
| Professional | | $376.16 | $502.87 | $3,174.90 |
- 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
- $734.00 / $1,024.00 / $1,549.00
| Professional | | $734.00 | $1,024.00 | $1,549.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.22 / $827.28 / $1,515.83
| Professional | | $497.22 | $827.28 | $1,515.83 |
- 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
- $742.76 / $1,068.29 / $1,643.52
| Professional | | $742.76 | $1,068.29 | $1,643.52 |