- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.38 / $2,081.76 / $2,969.56
| Professional | | $1,916.38 | $2,081.76 | $2,969.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,035.89 / $3,571.64 / $3,571.64
| Professional | | $3,035.89 | $3,571.64 | $3,571.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.00 / $2,900.00 / $2,958.00
| Facility | | $2,900.00 | $2,900.00 | $2,958.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.00 / $2,900.00 / $2,958.00
| Professional | | $2,465.00 | $2,900.00 | $2,958.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,220.54 / $3,000.62 / $5,001.04
| Professional | | $2,220.54 | $3,000.62 | $5,001.04 |