- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,731.40 / $2,218.48 / $2,218.48
| Professional | | $1,731.40 | $2,218.48 | $2,218.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,733.10 / $2,733.10 / $2,733.10
| Professional | | $2,733.10 | $2,733.10 | $2,733.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.13 / $2,569.13 / $2,569.13
| Facility | | $2,569.13 | $2,569.13 | $2,569.13 |
- 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
- $133.75 / $200.63 / $262.79
| Professional | | $133.75 | $200.63 | $262.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,124.94 / $3,462.36 / $4,406.64
| Professional | | $3,124.94 | $3,462.36 | $4,406.64 |