- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.33 / $1,180.33 / $1,475.42
| Professional | | $1,180.33 | $1,180.33 | $1,475.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $903.61 / $903.61 / $2,242.62
| Facility | | $903.61 | $903.61 | $2,242.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.00 / $7,159.00 / $7,159.00
| Professional | | $966.00 | $7,159.00 | $7,159.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $966.00 / $966.00 / $966.00
| Facility | | $966.00 | $966.00 | $966.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.00 / $1,113.82 / $1,140.33
| Professional | | $884.00 | $1,113.82 | $1,140.33 |