- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.54 / $2,407.54 / $2,407.54
| Professional | | $2,407.54 | $2,407.54 | $2,407.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,733.10 / $2,733.10 / $2,877.28
| Professional | | $2,733.10 | $2,733.10 | $2,877.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.13 / $2,569.13 / $4,080.53
| Facility | | $2,569.13 | $2,569.13 | $4,080.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.60 / $2,183.76 / $2,569.13
| Professional | | $295.60 | $2,183.76 | $2,569.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,731.40 / $1,731.40 / $2,407.54
| Professional | | $1,731.40 | $1,731.40 | $2,407.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.75 / $204.98 / $2,531.61
| Professional | | $133.75 | $204.98 | $2,531.61 |