- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.08 / $5,664.06 / $7,080.07
| Professional | | $1,093.08 | $5,664.06 | $7,080.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $9,292.00
| Professional | | $150.00 | $150.00 | $9,292.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,064.64 / $5,161.59 / $6,277.27
| Facility | | $1,064.64 | $5,161.59 | $6,277.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.10 / $5,070.20 / $17,882.24
| Professional | | $1,023.10 | $5,070.20 | $17,882.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,812.00 / $5,812.00 / $5,812.00
| Facility | | $5,812.00 | $5,812.00 | $5,812.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.10 / $4,466.00 / $6,211.82
| Professional | | $1,023.10 | $4,466.00 | $6,211.82 |