- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.36 / $2,711.90 / $3,158.91
| Professional | | $2,465.36 | $2,711.90 | $3,158.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,874.42 / $3,874.42 / $3,874.42
| Facility | | $3,874.42 | $3,874.42 | $3,874.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,329.37 / $2,691.00 / $2,711.51
| Professional | | $2,329.37 | $2,691.00 | $2,711.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.00 / $2,691.00 / $2,691.00
| Facility | | $2,691.00 | $2,691.00 | $2,691.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,348.01 / $2,711.51 / $4,538.91
| Professional | | $2,348.01 | $2,711.51 | $4,538.91 |