- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,622.23 / $2,136.67 / $2,211.21
| Professional | | $1,622.23 | $2,136.67 | $2,211.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,789.57 / $1,945.19 / $1,945.19
| Professional | | $1,789.57 | $1,945.19 | $1,945.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.64 / $1,219.64 / $2,915.20
| Facility | | $1,219.64 | $1,219.64 | $2,915.20 |
- 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 / $1,205.82 / $1,842.46
| Professional | | $838.43 | $1,205.82 | $1,842.46 |