- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.58 / $3,461.60 / $3,553.33
| Professional | | $2,711.58 | $3,461.60 | $3,553.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,834.49 / $3,593.34 / $3,593.34
| Professional | | $2,834.49 | $3,593.34 | $3,593.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,244.00
| Facility | | $2,200.00 | $2,200.00 | $2,244.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.00 / $2,200.00 / $2,244.00
| Professional | | $1,870.00 | $2,200.00 | $2,244.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,242.57 / $3,242.57 / $3,242.57
| Professional | | $3,242.57 | $3,242.57 | $3,242.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.75 / $2,372.46 / $3,510.78
| Professional | | $1,808.75 | $2,372.46 | $3,510.78 |