- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,738.60 / $4,177.56 / $4,708.37
| Professional | | $3,738.60 | $4,177.56 | $4,708.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,786.59 / $3,182.33 / $3,182.33
| Professional | | $2,786.59 | $3,182.33 | $3,182.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.00 / $2,187.00 / $2,187.00
| Facility | | $2,187.00 | $2,187.00 | $2,187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,858.95 / $2,187.00 / $4,550.89
| Professional | | $1,858.95 | $2,187.00 | $4,550.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.65 / $2,299.44 / $3,295.82
| Professional | | $1,776.65 | $2,299.44 | $3,295.82 |