- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,568.04 / $2,718.32 / $2,799.86
| Professional | | $2,568.04 | $2,718.32 | $2,799.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.86 / $2,683.03 / $2,735.04
| Professional | | $2,230.86 | $2,683.03 | $2,735.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,446.40
| Facility | | $2,446.40 | $2,446.40 | $2,446.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.94 / $2,446.40 / $4,372.50
| Professional | | $286.94 | $2,446.40 | $4,372.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.57 / $347.57 / $347.57
| Professional | | $347.57 | $347.57 | $347.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.68 / $1,435.76 / $2,998.13
| Professional | | $260.68 | $1,435.76 | $2,998.13 |