- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.10 / $1,665.10 / $3,379.00
| Professional | | $1,665.10 | $1,665.10 | $3,379.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,233.20 / $3,233.20 / $3,233.20
| Professional | | $3,233.20 | $3,233.20 | $3,233.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.31 / $2,416.31 / $2,416.31
| Facility | | $2,416.31 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,416.31 / $2,416.31 / $2,416.31
| Professional | | $2,416.31 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,228.59 / $1,425.18 / $2,290.60
| Professional | | $1,228.59 | $1,425.18 | $2,290.60 |