- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.86 / $2,230.84 / $2,754.83
| Professional | | $1,596.86 | $2,230.84 | $2,754.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,794.75 / $2,794.75 / $3,593.34
| Professional | | $2,794.75 | $2,794.75 | $3,593.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,244.00
| Facility | | $2,200.00 | $2,200.00 | $2,244.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.66 / $2,200.00 / $5,231.25
| Professional | | $354.66 | $2,200.00 | $5,231.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.08 / $488.08 / $488.08
| Professional | | $488.08 | $488.08 | $488.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,627.87 / $2,263.38 / $3,772.30
| Professional | | $1,627.87 | $2,263.38 | $3,772.30 |