- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,137.96 / $2,290.87
| Professional | | $1,905.46 | $2,137.96 | $2,290.87 |
- 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
- $2,041.74 / $2,041.74 / $2,398.83
| Professional | | $2,041.74 | $2,041.74 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $269.15 / $1,778.28
| Facility | | $162.18 | $269.15 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $2,290.87
| Professional | | $1,096.48 | $1,412.54 | $2,290.87 |