- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,340.83 / $2,305.00 / $6,800.28
| Professional | | $1,340.83 | $2,305.00 | $6,800.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $431.72 / $1,483.56 / $2,496.87
| Facility | | $431.72 | $1,483.56 | $2,496.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,914.00 / $1,914.00 / $1,914.00
| Professional | | $1,914.00 | $1,914.00 | $1,914.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.80 / $476.00 / $2,905.30
| Professional | | $445.80 | $476.00 | $2,905.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $876.99 / $985.31 / $12,000.00
| Facility | | $876.99 | $985.31 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,273.61 / $6,190.86 / $6,324.33
| Professional | | $2,273.61 | $6,190.86 | $6,324.33 |