- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.63 / $1,162.51 / $9,157.42
| Professional | | $494.63 | $1,162.51 | $9,157.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.40 / $1,650.40 / $1,650.40
| Facility | | $1,650.40 | $1,650.40 | $1,650.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.00 / $1,246.00 / $2,006.00
| Professional | | $1,038.00 | $1,246.00 | $2,006.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.91 / $1,018.44 / $1,306.14
| Professional | | $629.91 | $1,018.44 | $1,306.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.27 / $1,010.66 / $1,628.91
| Professional | | $542.27 | $1,010.66 | $1,628.91 |