- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.18 / $1,427.32 / $1,997.34
| Professional | | $932.18 | $1,427.32 | $1,997.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,026.29 / $2,026.29 / $2,433.71
| Professional | | $2,026.29 | $2,026.29 | $2,433.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.00 / $1,440.00 / $1,468.80
| Facility | | $1,440.00 | $1,440.00 | $1,468.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.64 / $1,440.00 / $3,832.50
| Professional | | $233.64 | $1,440.00 | $3,832.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.58 / $330.58 / $330.58
| Professional | | $330.58 | $330.58 | $330.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.28 / $1,391.26 / $2,318.76
| Professional | | $950.28 | $1,391.26 | $2,318.76 |