- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.38 / $1,917.76 / $3,841.94
| Professional | | $697.38 | $1,917.76 | $3,841.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $406.98 / $1,871.73 / $2,900.57
| Facility | | $406.98 | $1,871.73 | $2,900.57 |
- 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 / $2,735.12
| Professional | | $677.71 | $2,394.00 | $2,735.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.64 / $2,275.54 / $2,313.59
| Professional | | $305.64 | $2,275.54 | $2,313.59 |