- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.47 / $453.13 / $1,038.65
| Professional | | $293.47 | $453.13 | $1,038.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,846.40 / $5,846.40 / $5,846.40
| Facility | | $5,846.40 | $5,846.40 | $5,846.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.00 / $979.00 / $2,377.00
| Professional | | $608.00 | $979.00 | $2,377.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $912.00 / $1,762.50 / $3,565.50
| Professional | 50 | $912.00 | $1,762.50 | $3,565.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.52 / $1,084.77 / $1,893.66
| Professional | | $425.52 | $1,084.77 | $1,893.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.15 / $1,671.85 / $3,688.08
| Professional | | $1,196.15 | $1,671.85 | $3,688.08 |