- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.52 / $1,014.76 / $11,036.70
| Professional | | $600.52 | $1,014.76 | $11,036.70 |
- 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
- $1,150.00 / $1,740.00 / $2,934.00
| Professional | | $1,150.00 | $1,740.00 | $2,934.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.05 / $1,350.50 / $2,537.54
| Professional | | $920.05 | $1,350.50 | $2,537.54 |
- 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
- $1,412.36 / $2,026.91 / $3,150.63
| Professional | | $1,412.36 | $2,026.91 | $3,150.63 |