- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.00 / $477.00 / $2,590.71
| Professional | | $477.00 | $477.00 | $2,590.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $6,478.58 / $7,314.06
| Facility | | $0.02 | $6,478.58 | $7,314.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,186.22 / $4,186.22 / $4,186.22
| Professional | | $4,186.22 | $4,186.22 | $4,186.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,341.93 / $9,341.93 / $9,341.93
| Facility | | $9,341.93 | $9,341.93 | $9,341.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,895.65 / $4,556.83
| Professional | | $1,326.96 | $1,895.65 | $4,556.83 |