- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.49 / $546.49 / $3,865.44
| Professional | | $546.49 | $546.49 | $3,865.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,327.38 / $8,980.00 / $10,286.21
| Facility | | $1,327.38 | $8,980.00 | $10,286.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,070.20 / $17,882.24 / $17,882.24
| Professional | | $5,070.20 | $17,882.24 | $17,882.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $641.58 / $1,412.40 / $5,868.86
| Facility | | $641.58 | $1,412.40 | $5,868.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.50 / $906.50 / $906.50
| Professional | | $906.50 | $906.50 | $906.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $641.58 / $1,412.40 / $5,868.86
| Facility | | $641.58 | $1,412.40 | $5,868.86 |