- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,982.30 / $2,363.88 / $2,446.34
| Professional | | $1,982.30 | $2,363.88 | $2,446.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,979.91 / $2,152.08 / $2,152.08
| Professional | | $1,979.91 | $2,152.08 | $2,152.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.00 / $1,440.00 / $3,225.16
| Facility | | $1,440.00 | $1,440.00 | $3,225.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.64 / $1,440.00 / $3,832.50
| Professional | | $233.64 | $1,440.00 | $3,832.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.50 / $1,343.00 / $2,038.19
| Professional | | $927.50 | $1,343.00 | $2,038.19 |