- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,293.04 / $3,602.93 / $3,710.48
| Professional | | $3,293.04 | $3,602.93 | $3,710.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,182.33 / $3,313.20 / $3,764.25
| Professional | | $3,182.33 | $3,313.20 | $3,764.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.00 / $2,187.00 / $2,187.00
| Facility | | $2,187.00 | $2,187.00 | $2,187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.04 / $2,187.00 / $6,363.75
| Professional | | $418.04 | $2,187.00 | $6,363.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.36 / $534.36 / $534.36
| Professional | | $534.36 | $534.36 | $534.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,206.91 / $1,866.88 / $3,807.20
| Professional | | $1,206.91 | $1,866.88 | $3,807.20 |