- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,543.83 / $2,901.44 / $2,901.44
| Professional | | $2,543.83 | $2,901.44 | $2,901.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,470.00 / $2,569.13 / $2,569.13
| Facility | | $2,470.00 | $2,569.13 | $2,569.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,183.76 / $2,569.13 / $6,060.94
| Professional | | $2,183.76 | $2,569.13 | $6,060.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.41 / $2,901.44 / $3,113.04
| Facility | | $273.41 | $2,901.44 | $3,113.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.32 / $204.79 / $518.70
| Professional | | $150.32 | $204.79 | $518.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.00 / $100.00 / $100.00
| Facility | | $80.00 | $100.00 | $100.00 |