- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,570.40 / $2,884.03
| Professional | | $2,398.83 | $2,570.40 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,238.72
| Professional | | $1,905.46 | $1,905.46 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $288.40 / $2,187.76
| Facility | | $151.36 | $288.40 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,454.71 / $2,884.03
| Professional | | $1,479.11 | $2,454.71 | $2,884.03 |