- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,890.45 / $3,890.45
| Professional | | $2,818.38 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $3,630.78 / $7,079.46
| Professional | | $436.52 | $3,630.78 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,890.45 / $4,365.16
| Facility | | $2,951.21 | $3,890.45 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $602.56 / $2,818.38
| Facility | | $223.87 | $602.56 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,137.96 / $3,548.13
| Professional | | $1,479.11 | $2,137.96 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $5,248.07 / $5,248.07
| Facility | | $100.00 | $5,248.07 | $5,248.07 |