- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,244.96 / $2,841.81 / $3,202.32
| Professional | | $2,244.96 | $2,841.81 | $3,202.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,741.02 / $2,741.02 / $2,741.02
| Professional | | $2,741.02 | $2,741.02 | $2,741.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $2,673.00
| Facility | | $2,673.00 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.05 / $2,673.00 / $2,673.00
| Professional | | $2,272.05 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.00 / $1,931.84 / $3,219.73
| Professional | | $1,559.00 | $1,931.84 | $3,219.73 |