- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.66 / $892.07 / $4,337.64
| Professional | | $713.66 | $892.07 | $4,337.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,209.06 / $1,209.06 / $7,648.70
| Facility | | $1,209.06 | $1,209.06 | $7,648.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,927.00 / $10,567.34 / $10,567.34
| Professional | | $3,927.00 | $10,567.34 | $10,567.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,312.00 / $4,312.00 / $4,312.00
| Facility | | $4,312.00 | $4,312.00 | $4,312.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.42 / $3,067.45 / $3,946.00
| Professional | | $580.42 | $3,067.45 | $3,946.00 |