- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.61 / $1,359.53 / $6,185.08
| Professional | | $1,087.61 | $1,359.53 | $6,185.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $6,250.16 / $6,250.16
| Professional | | $150.00 | $6,250.16 | $6,250.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $983.07 / $3,862.25 / $4,595.08
| Facility | | $983.07 | $3,862.25 | $4,595.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $913.00 / $9,451.00 / $10,880.52
| Professional | | $913.00 | $9,451.00 | $10,880.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,123.00 / $4,123.00 / $4,123.00
| Facility | | $4,123.00 | $4,123.00 | $4,123.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.36 / $4,123.00 / $4,557.00
| Professional | | $953.36 | $4,123.00 | $4,557.00 |