- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.92 / $2,293.42 / $3,124.37
| Professional | | $1,475.92 | $2,293.42 | $3,124.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,938.71 / $2,451.23 / $2,570.80
| Professional | | $1,938.71 | $2,451.23 | $2,570.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,160.00 / $2,160.00 / $2,160.00
| Facility | | $2,160.00 | $2,160.00 | $2,160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.00 / $2,160.00 / $2,904.98
| Professional | | $1,836.00 | $2,160.00 | $2,904.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.96 / $1,429.23 / $15,669.80
| Facility | | $202.96 | $1,429.23 | $15,669.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.34 / $1,562.56 / $2,896.93
| Professional | | $1,115.34 | $1,562.56 | $2,896.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.00 / $1,463.03 / $2,922.73
| Professional | | $1,133.00 | $1,463.03 | $2,922.73 |