- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.00 / $440.00 / $5,767.71
| Professional | | $440.00 | $440.00 | $5,767.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,501.35 / $1,501.35 / $1,501.35
| Facility | | $1,501.35 | $1,501.35 | $1,501.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.84 / $1,288.56 / $2,015.02
| Professional | | $1,030.84 | $1,288.56 | $2,015.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,501.35 / $1,501.35 / $1,501.35
| Facility | | $1,501.35 | $1,501.35 | $1,501.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.04 / $1,030.84 / $2,015.02
| Professional | | $583.04 | $1,030.84 | $2,015.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.81 / $538.20 / $2,072.42
| Professional | | $391.81 | $538.20 | $2,072.42 |