- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,381.29 / $3,381.29 / $4,226.62
| Professional | | $3,381.29 | $3,381.29 | $4,226.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $2,732.00 / $6,134.82
| Facility | | $55.00 | $2,732.00 | $6,134.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.00 / $3,399.00 / $19,602.00
| Professional | | $2,732.00 | $3,399.00 | $19,602.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,875.36 / $2,430.46 / $2,732.00
| Facility | | $1,875.36 | $2,430.46 | $2,732.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.74 / $3,115.00 / $3,805.44
| Professional | | $1,680.74 | $3,115.00 | $3,805.44 |