- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.65 / $2,480.65 / $3,100.82
| Professional | | $2,480.65 | $2,480.65 | $3,100.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $2,946.50 / $2,946.50
| Professional | | $150.00 | $2,946.50 | $2,946.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,974.00 / $2,000.00 / $4,253.85
| Facility | | $1,974.00 | $2,000.00 | $4,253.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.00 / $2,330.41 / $5,897.00
| Professional | | $1,336.00 | $2,330.41 | $5,897.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,379.18 / $1,787.41 / $1,974.00
| Facility | | $1,379.18 | $1,787.41 | $1,974.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.00 / $1,971.97 / $2,443.21
| Professional | | $1,336.00 | $1,971.97 | $2,443.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.00 / $2,184.80 / $2,632.60
| Professional | | $6.00 | $2,184.80 | $2,632.60 |