- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.00 / $779.72 / $2,880.00
| Professional | | $601.00 | $779.72 | $2,880.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,978.91 / $3,699.93 / $7,707.87
| Facility | | $2,978.91 | $3,699.93 | $7,707.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.37 / $779.37 / $2,480.56
| Professional | | $779.37 | $779.37 | $2,480.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.38 / $961.23 / $2,480.56
| Professional | | $529.38 | $961.23 | $2,480.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.57 / $1,016.10 / $2,480.56
| Professional | | $664.57 | $1,016.10 | $2,480.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.68 / $915.64 / $3,044.61
| Professional | | $691.68 | $915.64 | $3,044.61 |