- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $632.94 / $664.37 / $4,904.50
| Professional | | $632.94 | $664.37 | $4,904.50 |
- 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
- $1,215.00 / $1,458.00 / $2,206.00
| Professional | | $1,215.00 | $1,458.00 | $2,206.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.74 / $1,265.86 / $1,761.75
| Professional | | $854.74 | $1,265.86 | $1,761.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.02 / $1,252.35 / $1,986.40
| Professional | | $881.02 | $1,252.35 | $1,986.40 |