- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.00 / $1,494.00 / $2,616.50
| Professional | | $1,494.00 | $1,494.00 | $2,616.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,918.00 / $2,918.00 / $2,918.00
| Professional | | $2,918.00 | $2,918.00 | $2,918.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.64 / $1,219.64 / $2,460.79
| Facility | | $1,219.64 | $1,219.64 | $2,460.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.64 / $1,219.64 / $1,219.64
| Professional | | $1,219.64 | $1,219.64 | $1,219.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.80 / $1,257.65 / $1,908.53
| Professional | | $1,073.80 | $1,257.65 | $1,908.53 |