- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.46 / $2,078.69 / $2,102.05
| Professional | | $1,201.46 | $2,078.69 | $2,102.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.85 / $1,932.85 / $1,932.85
| Professional | | $1,932.85 | $1,932.85 | $1,932.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.64 / $2,217.64 / $2,217.64
| Facility | | $2,217.64 | $2,217.64 | $2,217.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.13 / $2,217.64 / $3,059.25
| Professional | | $2,074.13 | $2,217.64 | $3,059.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.33 / $1,324.07 / $2,017.09
| Professional | | $840.33 | $1,324.07 | $2,017.09 |