- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,628.68 / $2,628.68 / $3,285.85
| Professional | | $2,628.68 | $2,628.68 | $3,285.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $3,621.24
| Professional | | $150.00 | $150.00 | $3,621.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,160.98 / $2,634.27 / $5,682.77
| Facility | | $2,160.98 | $2,634.27 | $5,682.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,412.00 / $2,748.72 / $15,682.00
| Professional | | $2,412.00 | $2,748.72 | $15,682.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,412.00 / $2,412.00 / $2,412.00
| Facility | | $2,412.00 | $2,412.00 | $2,412.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.51 / $2,513.00 / $2,748.72
| Professional | | $1,445.51 | $2,513.00 | $2,748.72 |