- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,201.27 / $5,201.27 / $6,501.59
| Professional | | $5,201.27 | $5,201.27 | $6,501.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $6,713.25
| Professional | | $150.00 | $150.00 | $6,713.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $4,502.00 / $10,014.09
| Facility | | $55.00 | $4,502.00 | $10,014.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,502.00 / $4,945.07 / $31,534.00
| Professional | | $4,502.00 | $4,945.07 | $31,534.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,911.83 / $3,773.73 / $4,502.00
| Facility | | $2,911.83 | $3,773.73 | $4,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,600.76 / $4,815.00 / $5,228.35
| Professional | | $2,600.76 | $4,815.00 | $5,228.35 |