- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.00 / $1,927.26 / $2,196.17
| Professional | | $1,416.00 | $1,927.26 | $2,196.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.21 / $1,754.58 / $1,754.58
| Professional | | $1,614.21 | $1,754.58 | $1,754.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.78 / $1,208.78 / $2,629.43
| Facility | | $1,208.78 | $1,208.78 | $2,629.43 |
- 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 / $1,243.16 / $1,661.64
| Professional | | $756.15 | $1,243.16 | $1,661.64 |