- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,861.12 / $3,085.02 / $3,177.11
| Professional | | $2,861.12 | $3,085.02 | $3,177.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,715.41 / $3,223.15 / $3,223.15
| Professional | | $2,715.41 | $3,223.15 | $3,223.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $3,349.85
| Facility | | $3,349.85 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.67 / $3,349.85 / $5,261.25
| Professional | | $356.67 | $3,349.85 | $5,261.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.81 / $453.81 / $453.81
| Professional | | $453.81 | $453.81 | $453.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,456.47 / $1,741.32 / $3,093.00
| Professional | | $1,456.47 | $1,741.32 | $3,093.00 |