- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.04 / $2,531.60 / $2,607.17
| Professional | | $1,960.04 | $2,531.60 | $2,607.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,644.95 / $2,691.00 / $3,156.96
| Professional | | $2,644.95 | $2,691.00 | $3,156.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.05 / $2,225.05 / $2,225.05
| Facility | | $2,225.05 | $2,225.05 | $2,225.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.68 / $2,225.05 / $5,261.25
| Professional | | $343.68 | $2,225.05 | $5,261.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.51 / $431.51 / $431.51
| Professional | | $431.51 | $431.51 | $431.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.64 / $1,433.05 / $2,436.90
| Professional | | $1,186.64 | $1,433.05 | $2,436.90 |