- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,752.02 / $5,165.34 / $5,165.34
| Professional | | $3,752.02 | $5,165.34 | $5,165.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.43 / $214.43 / $268.04
| Facility | | $214.43 | $214.43 | $268.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,529.88 / $5,575.23 / $7,735.63
| Professional | | $4,529.88 | $5,575.23 | $7,735.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.00 / $2,900.00 / $2,900.00
| Facility | | $2,900.00 | $2,900.00 | $2,900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.00 / $2,900.00 / $7,878.75
| Professional | | $2,465.00 | $2,900.00 | $7,878.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,860.57 / $4,246.80 / $30,495.32
| Facility | | $1,860.57 | $4,246.80 | $30,495.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,998.49 / $2,860.46 / $4,341.33
| Professional | | $1,998.49 | $2,860.46 | $4,341.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,274.03 / $2,860.46 / $4,341.33
| Professional | | $2,274.03 | $2,860.46 | $4,341.33 |