- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.20 / $2,224.03 / $2,354.85
| Professional | | $1,257.20 | $2,224.03 | $2,354.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,365.03 / $2,365.03 / $2,365.03
| Professional | | $2,365.03 | $2,365.03 | $2,365.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.64 / $1,219.64 / $1,219.64
| Facility | | $1,219.64 | $1,219.64 | $1,219.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.18 / $1,219.64 / $3,465.00
| Professional | | $211.18 | $1,219.64 | $3,465.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.43 / $1,257.65 / $1,991.28
| Professional | | $838.43 | $1,257.65 | $1,991.28 |