- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.33 / $1,001.68 / $1,277.18
| Professional | | $998.33 | $1,001.68 | $1,277.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,116.00 / $6,116.00 / $6,116.00
| Facility | | $6,116.00 | $6,116.00 | $6,116.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.00 / $2,292.00 / $3,468.00
| Professional | | $1,910.00 | $2,292.00 | $3,468.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.16 / $1,789.74 / $2,772.70
| Professional | | $1,193.16 | $1,789.74 | $2,772.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.64 / $1,975.36 / $3,070.50
| Professional | | $1,389.64 | $1,975.36 | $3,070.50 |