- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $1,584.89
| Professional | | $831.76 | $1,202.26 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,621.81
| Facility | | $1,230.27 | $1,230.27 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,230.27 / $2,137.96
| Professional | | $1,023.29 | $1,230.27 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $776.25 / $1,412.54
| Facility | | $100.00 | $776.25 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,000.00 / $1,698.24
| Professional | | $660.69 | $1,000.00 | $1,698.24 |