- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,959.02 / $2,959.02 / $3,698.78
| Professional | | $2,959.02 | $2,959.02 | $3,698.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $2,574.27 / $5,272.80
| Facility | | $55.00 | $2,574.27 | $5,272.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.27 / $5,025.06 / $9,923.04
| Professional | | $2,574.27 | $5,025.06 | $9,923.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,605.69 / $2,574.27 / $3,073.33
| Facility | | $1,605.69 | $2,574.27 | $3,073.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,080.96 / $2,670.60 / $5,025.06
| Professional | | $2,080.96 | $2,670.60 | $5,025.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $3.00 / $3,304.00
| Professional | | $3.00 | $3.00 | $3,304.00 |