- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $575.44 / $1,023.29
| Professional | | $407.38 | $575.44 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $691.83 / $977.24
| Facility | | $346.74 | $691.83 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $575.44 / $977.24
| Professional | | $60.26 | $575.44 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,019.95
| Professional | | $2,818.38 | $2,818.38 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $831.76 / $1,000.00
| Facility | | $691.83 | $831.76 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $977.24
| Professional | | $60.26 | $60.26 | $977.24 |