- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.68 / $451.50 / $3,183.30
| Professional | | $335.68 | $451.50 | $3,183.30 |
- 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
- $647.00 / $916.00 / $1,385.00
| Professional | | $647.00 | $916.00 | $1,385.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $444.81 / $736.23 / $1,352.70
| Professional | | $444.81 | $736.23 | $1,352.70 |
- 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
- $522.89 / $961.22 / $1,537.91
| Professional | | $522.89 | $961.22 | $1,537.91 |