- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,218.85 / $7,001.33 / $7,001.33
| Professional | | $2,218.85 | $7,001.33 | $7,001.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.35 / $5,506.05 / $6,596.87
| Professional | | $1,549.35 | $5,506.05 | $6,596.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $2,102.75
| Professional | | $32.34 | $32.34 | $2,102.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,357.22 / $1,834.27 / $3,400.00
| Facility | | $1,357.22 | $1,834.27 | $3,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,581.42 / $3,180.78 / $4,849.50
| Professional | | $1,581.42 | $3,180.78 | $4,849.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,430.08 / $1,918.40 / $3,137.08
| Professional | | $1,430.08 | $1,918.40 | $3,137.08 |