- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,248.61 / $2,474.42 / $3,093.03
| Professional | | $2,248.61 | $2,474.42 | $3,093.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $2,872.86 / $2,872.86
| Professional | | $150.00 | $2,872.86 | $2,872.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,422.28 / $1,719.71 / $2,492.62
| Facility | | $1,422.28 | $1,719.71 | $2,492.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,591.00 / $5,494.34 / $5,494.34
| Professional | | $1,591.00 | $5,494.34 | $5,494.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,853.00 / $1,853.00 / $1,853.00
| Facility | | $1,853.00 | $1,853.00 | $1,853.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.23 / $1,752.00 / $2,336.73
| Professional | | $1,251.23 | $1,752.00 | $2,336.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $2,141.50 / $2,580.40
| Professional | | $7.00 | $2,141.50 | $2,580.40 |