- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.40 / $2,386.71 / $2,386.71
| Professional | | $1,640.40 | $2,386.71 | $2,386.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Facility | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.97 / $2,225.09 / $3,768.75
| Professional | | $274.97 | $2,225.09 | $3,768.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.40 / $2,386.71 / $2,819.16
| Facility | | $1,640.40 | $2,386.71 | $2,819.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,533.00 / $2,533.00 / $2,819.16
| Professional | | $2,533.00 | $2,533.00 | $2,819.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.07 / $1,273.76 / $2,167.40
| Professional | | $835.07 | $1,273.76 | $2,167.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $17,266.63 / $17,266.63
| Facility | | $100.00 | $17,266.63 | $17,266.63 |