- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,413.26 / $2,413.26 / $3,180.16
| Professional | | $2,413.26 | $2,413.26 | $3,180.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,400.00 / $3,000.00 / $3,782.21
| Professional | | $2,400.00 | $3,000.00 | $3,782.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.05 / $2,225.05 / $2,648.78
| Facility | | $2,225.05 | $2,225.05 | $2,648.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.68 / $2,225.05 / $2,225.05
| Professional | | $343.68 | $2,225.05 | $2,225.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.15 / $2,413.26 / $3,180.16
| Facility | | $437.15 | $2,413.26 | $3,180.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.31 / $11,586.00 / $11,586.00
| Professional | | $1,713.31 | $11,586.00 | $11,586.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.97 / $1,433.05 / $2,953.71
| Professional | | $978.97 | $1,433.05 | $2,953.71 |