- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.75 / $1,154.75 / $2,022.30
| Professional | | $1,154.75 | $1,154.75 | $2,022.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.40 / $2,255.40 / $2,255.40
| Professional | | $2,255.40 | $2,255.40 | $2,255.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.00 / $1,071.00 / $1,902.03
| Facility | | $1,071.00 | $1,071.00 | $1,902.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.00 / $1,071.00 / $1,071.00
| Professional | | $1,071.00 | $1,071.00 | $1,071.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.08 / $972.04 / $1,475.35
| Professional | | $830.08 | $972.04 | $1,475.35 |