- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,515.28 / $2,767.28 / $2,994.38
| Professional | | $2,515.28 | $2,767.28 | $2,994.38 |
- 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 / $1,870.00 / $2,244.00
| Professional | | $1,870.00 | $1,870.00 | $2,244.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,106.14 / $3,106.14 / $3,106.14
| Professional | | $3,106.14 | $3,106.14 | $3,106.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.92 / $2,263.38 / $3,084.77
| Professional | | $1,508.92 | $2,263.38 | $3,084.77 |