- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,707.39 / $2,979.28 / $3,724.10
| Professional | | $2,707.39 | $2,979.28 | $3,724.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,106.46 / $2,806.72 / $3,784.12
| Facility | | $2,106.46 | $2,806.72 | $3,784.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,341.00 / $15,341.00 / $15,341.00
| Professional | | $15,341.00 | $15,341.00 | $15,341.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,602.00 / $2,602.00 / $2,602.00
| Facility | | $2,602.00 | $2,602.00 | $2,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.00 / $2,648.00 / $2,837.89
| Professional | | $2,382.00 | $2,648.00 | $2,837.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.65 / $2,440.90 / $2,878.22
| Professional | | $1,748.65 | $2,440.90 | $2,878.22 |