- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,768.77 / $2,352.67 / $2,352.67
| Professional | | $1,768.77 | $2,352.67 | $2,352.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,750.77 / $2,462.00 / $2,561.83
| Professional | | $1,750.77 | $2,462.00 | $2,561.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.33 / $303.33 / $2,063.21
| Facility | | $303.33 | $303.33 | $2,063.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $257.83 / $303.33
| Professional | | $192.51 | $257.83 | $303.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,768.77 / $2,250.36 / $2,352.67
| Professional | | $1,768.77 | $2,250.36 | $2,352.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.49 / $516.46 / $2,599.73
| Professional | | $150.49 | $516.46 | $2,599.73 |