- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.60 / $1,347.60 / $2,360.00
| Professional | | $1,347.60 | $1,347.60 | $2,360.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,632.00 / $2,632.00 / $2,632.00
| Professional | | $2,632.00 | $2,632.00 | $2,632.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.78 / $1,208.78 / $2,219.42
| Facility | | $1,208.78 | $1,208.78 | $2,219.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.78 / $1,208.78 / $1,208.78
| Professional | | $1,208.78 | $1,208.78 | $1,208.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.63 / $1,134.22 / $1,721.59
| Professional | | $968.63 | $1,134.22 | $1,721.59 |