- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.65 / $1,297.65 / $2,272.60
| Professional | | $1,297.65 | $1,297.65 | $2,272.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,534.50 / $2,534.50 / $2,534.50
| Professional | | $2,534.50 | $2,534.50 | $2,534.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,436.52 / $1,436.52 / $2,137.21
| Facility | | $1,436.52 | $1,436.52 | $2,137.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.52 / $1,436.52 / $1,436.52
| Professional | | $1,436.52 | $1,436.52 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.71 / $1,092.43 / $1,657.76
| Professional | | $932.71 | $1,092.43 | $1,657.76 |