- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.13 / $946.50 / $1,171.41
| Professional | | $937.13 | $946.50 | $1,171.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $810.00 / $810.00 / $8,615.98
| Facility | | $810.00 | $810.00 | $8,615.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.00 / $2,996.65 / $2,996.65
| Professional | | $810.00 | $2,996.65 | $2,996.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $810.00 / $810.00 / $1,263.58
| Facility | | $810.00 | $810.00 | $1,263.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.75 / $1,061.21 / $1,781.66
| Professional | | $771.75 | $1,061.21 | $1,781.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.40 / $1,215.80 / $1,504.60
| Professional | | $27.40 | $1,215.80 | $1,504.60 |