- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,872.50 / $2,892.00 / $3,351.12
| Professional | | $2,872.50 | $2,892.00 | $3,351.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.01 / $2,852.72 / $2,852.72
| Professional | | $2,344.01 | $2,852.72 | $2,852.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,270.91 / $2,671.66 / $2,671.66
| Professional | | $2,270.91 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.05 / $1,575.56 / $2,478.39
| Professional | | $1,275.05 | $1,575.56 | $2,478.39 |