- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.00 / $1,036.00 / $1,195.39
| Professional | | $1,036.00 | $1,036.00 | $1,195.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,407.05 / $1,407.05 / $1,407.05
| Facility | | $1,407.05 | $1,407.05 | $1,407.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.15 / $1,027.15 / $1,027.15
| Professional | | $1,027.15 | $1,027.15 | $1,027.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,407.05 / $1,407.05 / $1,407.05
| Facility | | $1,407.05 | $1,407.05 | $1,407.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.15 / $1,027.15 / $1,027.15
| Professional | | $1,027.15 | $1,027.15 | $1,027.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.34 / $1,257.59 / $2,454.30
| Professional | | $734.34 | $1,257.59 | $2,454.30 |