- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.46 / $3,612.02 / $3,822.06
| Professional | | $2,679.46 | $3,612.02 | $3,822.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.75 / $459.71 / $459.71
| Professional | | $390.75 | $459.71 | $459.71 |
- 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 / $2,187.00
| Professional | | $1,858.95 | $2,187.00 | $2,187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.74 / $2,377.67 / $3,962.80
| Professional | | $1,860.74 | $2,377.67 | $3,962.80 |