- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,336.35 / $3,201.26 / $3,201.26
| Professional | | $2,336.35 | $3,201.26 | $3,201.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,019.14 / $5,100.00 / $5,100.00
| Professional | | $4,019.14 | $5,100.00 | $5,100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.17 / $306.17 / $306.17
| Facility | | $306.17 | $306.17 | $306.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $389.53
| Professional | | $248.35 | $248.35 | $389.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,248.12 / $3,201.26 / $3,201.26
| Professional | | $2,248.12 | $3,201.26 | $3,201.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.85 / $266.77 / $2,620.65
| Professional | | $177.85 | $266.77 | $2,620.65 |