- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,792.87 / $2,792.87 / $3,543.92
| Professional | | $2,792.87 | $2,792.87 | $3,543.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,200.00 / $4,000.00 / $5,042.93
| Professional | | $3,200.00 | $4,000.00 | $5,042.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,648.78 / $3,655.97 / $3,655.97
| Facility | | $2,648.78 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.69 / $3,655.97 / $3,655.97
| Professional | | $441.69 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $505.91 / $2,792.87 / $3,543.92
| Facility | | $505.91 | $2,792.87 | $3,543.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.00 / $1,513.00 / $1,513.00
| Professional | | $1,513.00 | $1,513.00 | $1,513.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.23 / $1,801.31 / $2,851.50
| Professional | | $1,395.23 | $1,801.31 | $2,851.50 |