- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $3,311.31
| Professional | | $1,949.84 | $2,630.27 | $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
- $2,041.74 / $2,398.83 / $2,398.83
| Professional | | $2,041.74 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $1,778.28
| Facility | | $199.53 | $199.53 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,412.54 / $2,344.23
| Professional | | $776.25 | $1,412.54 | $2,344.23 |