- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.27 / $2,016.01 / $2,552.90
| Professional | | $992.27 | $2,016.01 | $2,552.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,489.69 / $11,500.00 / $26,542.00
| Facility | | $1,489.69 | $11,500.00 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,562.42 / $2,562.42 / $2,562.42
| Professional | | $2,562.42 | $2,562.42 | $2,562.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $581.25 / $727.39 / $1,053.61
| Facility | | $581.25 | $727.39 | $1,053.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.00 / $729.90 / $1,103.40
| Professional | | $4.00 | $729.90 | $1,103.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $581.25 / $727.39 / $1,066.40
| Facility | | $581.25 | $727.39 | $1,066.40 |