- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.64 / $1,945.80 / $2,920.65
| Professional | | $1,556.64 | $1,945.80 | $2,920.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $2,429.01 / $2,429.01
| Professional | | $150.00 | $2,429.01 | $2,429.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,031.23 / $1,701.00 / $2,484.59
| Facility | | $1,031.23 | $1,701.00 | $2,484.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,368.39 / $4,292.00 / $4,714.54
| Professional | | $1,368.39 | $4,292.00 | $4,714.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,701.00 / $1,701.00 / $1,701.00
| Facility | | $1,701.00 | $1,701.00 | $1,701.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.96 / $1,701.00 / $2,133.46
| Professional | | $1,318.96 | $1,701.00 | $2,133.46 |