- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,769.70 / $2,130.77 / $3,465.69
| Professional | | $1,769.70 | $2,130.77 | $3,465.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $590.04 / $810.22 / $1,199.86
| Facility | | $590.04 | $810.22 | $1,199.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.00 / $767.00 / $767.00
| Professional | | $767.00 | $767.00 | $767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.60 / $638.50 / $1,049.40
| Professional | | $570.60 | $638.50 | $1,049.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,325.93 / $5,811.00 / $26,542.00
| Facility | | $1,325.93 | $5,811.00 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,562.42 / $2,562.42 / $2,562.42
| Professional | | $2,562.42 | $2,562.42 | $2,562.42 |