- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $7,244.36 / $7,244.36
| Professional | | $5,370.32 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $3,801.89 / $15,135.61
| Professional | | $776.25 | $3,801.89 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $7,244.36 / $8,128.31
| Facility | | $3,890.45 | $7,244.36 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,071.52 / $4,466.84
| Facility | | $302.00 | $1,071.52 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,311.31 / $5,495.41
| Professional | | $2,238.72 | $3,311.31 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $7,079.46 / $7,079.46
| Facility | | $100.00 | $7,079.46 | $7,079.46 |