- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $1,778.28
| Professional | | $741.31 | $1,047.13 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $3,162.28
| Facility | | $1,380.38 | $1,380.38 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $2,398.83
| Professional | | $1,000.00 | $1,000.00 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,318.26 / $2,398.83
| Facility | | $1,148.15 | $1,318.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $870.96 / $1,318.26
| Professional | | $575.44 | $870.96 | $1,318.26 |