- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.57 / $2,390.91 / $3,155.08
| Professional | | $1,885.57 | $2,390.91 | $3,155.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.73 / $2,204.86 / $2,278.19
| Professional | | $341.73 | $2,204.86 | $2,278.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $3,210.83
| Facility | | $2,446.40 | $2,446.40 | $3,210.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.00 / $2,446.40 / $4,372.50
| Professional | | $2,070.00 | $2,446.40 | $4,372.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.57 / $2,395.19 / $3,157.12
| Professional | | $1,885.57 | $2,395.19 | $3,157.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $3,210.83
| Facility | | $2,446.40 | $2,446.40 | $3,210.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.08 / $2,446.40 / $5,465.63
| Professional | | $321.08 | $2,446.40 | $5,465.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,717.68 / $4,134.10 / $4,214.60
| Professional | | $3,717.68 | $4,134.10 | $4,214.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.75 / $1,914.34 / $3,797.63
| Professional | | $1,383.75 | $1,914.34 | $3,797.63 |