- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.30 / $1,196.30 / $2,337.30
| Professional | | $1,196.30 | $1,196.30 | $2,337.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,606.69 / $2,606.69 / $2,606.69
| Professional | | $2,606.69 | $2,606.69 | $2,606.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $2,198.30
| Facility | | $1,639.62 | $1,639.62 | $2,198.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $1,639.62
| Professional | | $1,639.62 | $1,639.62 | $1,639.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.40 / $1,123.40 / $1,705.19
| Professional | | $959.40 | $1,123.40 | $1,705.19 |