- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,718.32 / $3,157.12 / $3,157.12
| Professional | | $2,718.32 | $3,157.12 | $3,157.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,446.40
| Facility | | $2,446.40 | $2,446.40 | $2,446.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,079.44 / $2,446.40 / $4,372.50
| Professional | | $2,079.44 | $2,446.40 | $4,372.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.48 / $3,157.12 / $3,788.54
| Facility | | $2,481.48 | $3,157.12 | $3,788.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,208.50 / $4,208.50 / $4,208.50
| Professional | | $4,208.50 | $4,208.50 | $4,208.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,382.40 / $1,823.52 / $3,767.80
| Professional | | $1,382.40 | $1,823.52 | $3,767.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $4,847.72 / $4,847.72
| Facility | | $100.00 | $4,847.72 | $4,847.72 |