- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $3,981.07
| Professional | | $1,862.09 | $2,630.27 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,691.53 / $2,754.23
| Professional | | $2,290.87 | $2,691.53 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $1,778.28 / $2,630.27
| Facility | | $239.88 | $1,778.28 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,041.74 / $3,467.37
| Professional | | $1,380.38 | $2,041.74 | $3,467.37 |