- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.08 / $1,454.64 / $2,124.00
| Professional | | $1,133.08 | $1,454.64 | $2,124.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,133.23 / $2,133.23 / $2,133.23
| Professional | | $2,133.23 | $2,133.23 | $2,133.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.78 / $1,208.78 / $1,208.78
| Facility | | $1,208.78 | $1,208.78 | $1,208.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.49 / $1,208.78 / $3,123.75
| Professional | | $190.49 | $1,208.78 | $3,123.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.15 / $1,131.95 / $1,824.89
| Professional | | $756.15 | $1,131.95 | $1,824.89 |