- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $739.37 / $924.21 / $5,100.18
| Professional | | $739.37 | $924.21 | $5,100.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $6,273.43
| Professional | | $150.00 | $150.00 | $6,273.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $715.43 / $3,340.51 / $7,130.43
| Facility | | $715.43 | $3,340.51 | $7,130.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.13 / $3,868.62 / $11,564.19
| Professional | | $705.13 | $3,868.62 | $11,564.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,118.00 / $4,118.00 / $4,118.00
| Facility | | $4,118.00 | $4,118.00 | $4,118.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.13 / $2,890.00 / $4,180.00
| Professional | | $705.13 | $2,890.00 | $4,180.00 |