- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,843.00 / $2,843.00 / $2,843.00
| Professional | | $2,843.00 | $2,843.00 | $2,843.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $368.13 / $563.38 / $987.84
| Facility | | $368.13 | $563.38 | $987.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,576.92 / $4,121.38 / $4,338.29
| Professional | | $3,576.92 | $4,121.38 | $4,338.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.00 / $1,438.00 / $3,367.00
| Facility | | $331.00 | $1,438.00 | $3,367.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $563.00 / $1,580.95 / $3,584.00
| Facility | | $563.00 | $1,580.95 | $3,584.00 |