- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,736.07 / $3,041.12 / $3,041.12
| Professional | | $2,736.07 | $3,041.12 | $3,041.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.69 / $2,290.69 / $3,006.51
| Facility | | $2,290.69 | $2,290.69 | $3,006.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.10 / $2,290.69 / $3,993.75
| Professional | | $1,947.10 | $2,290.69 | $3,993.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,318.42 / $3,041.12 / $3,641.40
| Facility | | $2,318.42 | $3,041.12 | $3,641.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,224.89 / $4,224.89 / $4,224.89
| Professional | | $4,224.89 | $4,224.89 | $4,224.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.97 / $329.01 / $2,829.98
| Facility | | $204.97 | $329.01 | $2,829.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.32 / $1,787.36 / $3,582.52
| Professional | | $1,385.32 | $1,787.36 | $3,582.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $4,879.47 / $4,879.47
| Facility | | $100.00 | $4,879.47 | $4,879.47 |