- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,591.19 / $3,537.93 / $3,617.20
| Professional | | $2,591.19 | $3,537.93 | $3,617.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.00 / $2,691.00 / $2,898.00
| Professional | | $2,691.00 | $2,691.00 | $2,898.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.05 / $2,225.05 / $2,225.05
| Facility | | $2,225.05 | $2,225.05 | $2,225.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,891.29 / $2,225.05 / $2,225.05
| Professional | | $1,891.29 | $2,225.05 | $2,225.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.27 / $1,594.98 / $2,172.83
| Professional | | $1,152.27 | $1,594.98 | $2,172.83 |