- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.25 / $1,753.06 / $1,805.39
| Professional | | $1,290.25 | $1,753.06 | $1,805.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,831.55 / $1,831.55 / $2,199.53
| Professional | | $1,831.55 | $1,831.55 | $2,199.53 |
- 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
- $298.80 / $298.80 / $298.80
| Professional | | $298.80 | $298.80 | $298.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.10 / $1,257.65 / $1,710.73
| Professional | | $224.10 | $1,257.65 | $1,710.73 |