- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,933.89 / $1,933.89 / $2,581.91
| Professional | | $1,933.89 | $1,933.89 | $2,581.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,553.94 / $1,553.94 / $1,626.26
| Professional | | $1,553.94 | $1,553.94 | $1,626.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $712.05 / $712.05 / $712.05
| Facility | | $712.05 | $712.05 | $712.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,241.54 / $2,593.46 / $3,978.51
| Professional | | $2,241.54 | $2,593.46 | $3,978.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,933.89 / $1,933.89 / $1,933.89
| Professional | | $1,933.89 | $1,933.89 | $1,933.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,856.17 / $2,579.07 / $3,335.01
| Professional | | $1,856.17 | $2,579.07 | $3,335.01 |