- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.65 / $1,284.39 / $3,126.50
| Professional | | $710.65 | $1,284.39 | $3,126.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,929.70 / $11,500.00 / $16,394.00
| Facility | | $1,929.70 | $11,500.00 | $16,394.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,225.29 / $3,225.29 / $3,225.29
| Professional | | $3,225.29 | $3,225.29 | $3,225.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $742.66 / $923.04 / $1,288.75
| Facility | | $742.66 | $923.04 | $1,288.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.00 / $872.00 / $872.00
| Professional | | $872.00 | $872.00 | $872.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $742.66 / $923.04 / $1,288.75
| Facility | | $742.66 | $923.04 | $1,288.75 |