- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.21 / $1,216.68 / $2,265.37
| Professional | | $581.21 | $1,216.68 | $2,265.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.43 / $619.66 / $1,130.48
| Facility | | $376.43 | $619.66 | $1,130.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.00 / $2,324.05 / $2,324.05
| Professional | | $2,122.00 | $2,324.05 | $2,324.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $813.00 / $813.00 / $813.00
| Facility | | $813.00 | $813.00 | $813.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.86 / $839.00 / $1,022.06
| Professional | | $555.86 | $839.00 | $1,022.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $651.29 / $1,413.70
| Professional | | $5.00 | $651.29 | $1,413.70 |