- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.85 / $1,547.85 / $2,710.70
| Professional | | $1,547.85 | $1,547.85 | $2,710.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,023.10 / $3,023.10 / $3,023.10
| Professional | | $3,023.10 | $3,023.10 | $3,023.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $2,549.46
| Facility | | $1,406.76 | $1,406.76 | $2,549.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,406.76
| Professional | | $1,406.76 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.63 / $1,302.91 / $1,457.41
| Professional | | $1,112.63 | $1,302.91 | $1,457.41 |