- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.21 / $1,347.21 / $2,106.54
| Professional | | $1,347.21 | $1,347.21 | $2,106.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,349.35 / $2,349.35 / $2,349.35
| Facility | | $2,349.35 | $2,349.35 | $2,349.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.35 / $2,349.35 / $2,349.35
| Professional | | $2,349.35 | $2,349.35 | $2,349.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.10 / $1,304.10 / $2,227.61
| Facility | | $1,304.10 | $1,304.10 | $2,227.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.00 / $952.00 / $1,304.10
| Professional | | $952.00 | $952.00 | $1,304.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.75 / $998.83 / $1,108.89
| Professional | | $902.75 | $998.83 | $1,108.89 |