- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.41 / $3,073.55 / $6,434.03
| Professional | | $767.41 | $3,073.55 | $6,434.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $427.71 / $722.85 / $2,869.64
| Facility | | $427.71 | $722.85 | $2,869.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,273.61 / $6,324.33 / $6,324.33
| Professional | | $2,273.61 | $6,324.33 | $6,324.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,616.00 / $2,616.00 / $2,616.00
| Facility | | $2,616.00 | $2,616.00 | $2,616.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.71 / $2,394.00 / $2,738.27
| Professional | | $677.71 | $2,394.00 | $2,738.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.00 / $511.40 / $4,032.60
| Professional | | $4.00 | $511.40 | $4,032.60 |