- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,089.30 / $2,089.30
| Professional | | $1,995.26 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Professional | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,230.27 / $1,513.56
| Professional | | $812.83 | $1,230.27 | $1,513.56 |