- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.06 / $1,794.13 / $2,271.92
| Professional | | $883.06 | $1,794.13 | $2,271.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,309.04 / $11,500.00 / $16,394.00
| Facility | | $3,309.04 | $11,500.00 | $16,394.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.96 / $2,243.96 / $2,243.96
| Professional | | $2,243.96 | $2,243.96 | $2,243.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $492.37 / $636.54 / $961.52
| Facility | | $492.37 | $636.54 | $961.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.00 / $828.90 / $949.90
| Professional | | $4.00 | $828.90 | $949.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.30 / $636.54 / $961.52
| Facility | | $496.30 | $636.54 | $961.52 |