- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,823.46 / $2,823.46 / $3,529.32
| Professional | | $2,823.46 | $2,823.46 | $3,529.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $3,528.70
| Professional | | $150.00 | $150.00 | $3,528.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,364.23 / $2,500.60 / $5,184.27
| Facility | | $2,364.23 | $2,500.60 | $5,184.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,381.00 / $2,643.00 / $13,636.00
| Professional | | $2,381.00 | $2,643.00 | $13,636.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,381.00 / $2,381.00 / $2,381.00
| Facility | | $2,381.00 | $2,381.00 | $2,381.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.01 / $2,446.00 / $2,643.00
| Professional | | $1,352.01 | $2,446.00 | $2,643.00 |