- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,563.10 / $2,819.54 / $3,128.35
| Professional | | $2,563.10 | $2,819.54 | $3,128.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,304.10 / $2,655.12 / $2,655.12
| Professional | | $2,304.10 | $2,655.12 | $2,655.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,254.90 / $2,254.90 / $2,254.90
| Facility | | $2,254.90 | $2,254.90 | $2,254.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.67 / $2,254.90 / $3,052.83
| Professional | | $1,916.67 | $2,254.90 | $3,052.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.80 / $1,482.72 / $2,272.07
| Professional | | $1,224.80 | $1,482.72 | $2,272.07 |