- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,345.21 / $3,140.93 / $3,140.93
| Professional | | $2,345.21 | $3,140.93 | $3,140.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.31 / $2,416.31 / $2,416.31
| Facility | | $2,416.31 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.86 / $2,416.31 / $2,416.31
| Professional | | $2,053.86 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.31 / $2,416.31 / $2,416.31
| Facility | | $2,416.31 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,416.31 / $2,416.31 / $2,416.31
| Professional | | $2,416.31 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.51 / $1,953.82 / $2,519.07
| Professional | | $309.51 | $1,953.82 | $2,519.07 |