- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.07 / $719.07 / $5,877.02
| Professional | | $719.07 | $719.07 | $5,877.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,529.81 / $1,529.81 / $1,529.81
| Facility | | $1,529.81 | $1,529.81 | $1,529.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.26 / $1,312.82 / $2,053.94
| Professional | | $1,050.26 | $1,312.82 | $2,053.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,529.81 / $1,529.81 / $1,529.81
| Facility | | $1,529.81 | $1,529.81 | $1,529.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.00 / $1,050.26 / $2,053.94
| Professional | | $640.00 | $1,050.26 | $2,053.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.24 / $548.40 / $2,111.71
| Professional | | $399.24 | $548.40 | $2,111.71 |