- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.35 / $1,262.00 / $9,823.00
| Professional | | $541.35 | $1,262.00 | $9,823.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,957.00 / $2,120.75 / $2,120.75
| Facility | | $1,957.00 | $2,120.75 | $2,120.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.00 / $672.00 / $1,000.00
| Professional | | $672.00 | $672.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $716.00 / $790.86 / $813.00
| Facility | | $716.00 | $790.86 | $813.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |