- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,741.45 / $3,244.18 / $4,095.00
| Professional | | $2,741.45 | $3,244.18 | $4,095.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,883.59 / $2,883.59 / $3,151.79
| Professional | | $2,883.59 | $2,883.59 | $3,151.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,702.68 / $2,937.70 / $2,937.70
| Professional | | $2,702.68 | $2,937.70 | $2,937.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $4,460.29
| Facility | | $2,200.00 | $2,200.00 | $4,460.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.66 / $2,200.00 / $5,231.25
| Professional | | $354.66 | $2,200.00 | $5,231.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.35 / $2,372.46 / $3,583.69
| Professional | | $1,550.35 | $2,372.46 | $3,583.69 |