- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,759.04 / $2,841.81 / $3,063.32
| Professional | | $2,759.04 | $2,841.81 | $3,063.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,617.98 / $3,107.72 / $3,107.72
| Professional | | $2,617.98 | $3,107.72 | $3,107.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $2,673.00
| Facility | | $2,673.00 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.88 / $2,673.00 / $5,073.75
| Professional | | $343.88 | $2,673.00 | $5,073.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.54 / $437.54 / $437.54
| Professional | | $437.54 | $437.54 | $437.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.77 / $1,678.96 / $3,245.92
| Professional | | $1,132.77 | $1,678.96 | $3,245.92 |