- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.84 / $1,144.84 / $2,004.90
| Professional | | $1,144.84 | $1,144.84 | $2,004.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,236.00 / $2,236.00 / $2,236.00
| Professional | | $2,236.00 | $2,236.00 | $2,236.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,082.51 / $1,082.51 / $1,885.47
| Facility | | $1,082.51 | $1,082.51 | $1,885.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.51 / $1,082.51 / $1,082.51
| Professional | | $1,082.51 | $1,082.51 | $1,082.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.89 / $963.59 / $1,462.57
| Professional | | $822.89 | $963.59 | $1,462.57 |