- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,731.40 / $2,318.80 / $2,318.80
| Professional | | $1,731.40 | $2,318.80 | $2,318.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.13 / $2,569.13 / $2,569.13
| Facility | | $2,569.13 | $2,569.13 | $2,569.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,183.76 / $2,183.76 / $2,183.76
| Professional | | $2,183.76 | $2,183.76 | $2,183.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.13 / $2,569.13 / $2,569.13
| Facility | | $2,569.13 | $2,569.13 | $2,569.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.75 / $334.38 / $2,250.32
| Professional | | $133.75 | $334.38 | $2,250.32 |