- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.31 / $772.31 / $772.31
| Professional | | $772.31 | $772.31 | $772.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.98 / $952.72 / $1,339.83
| Facility | | $741.98 | $952.72 | $1,339.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $3.00 / $1,999.90
| Professional | | $3.00 | $3.00 | $1,999.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,353.37 / $4,416.13 / $26,542.00
| Facility | | $1,353.37 | $4,416.13 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,870.00 / $3,870.00 / $3,870.00
| Professional | | $3,870.00 | $3,870.00 | $3,870.00 |