- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.62 / $2,636.03 / $2,745.98
| Professional | | $2,306.62 | $2,636.03 | $2,745.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.69 / $2,290.69 / $3,236.31
| Facility | | $2,290.69 | $2,290.69 | $3,236.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.10 / $1,947.10 / $3,236.31
| Professional | | $1,947.10 | $1,947.10 | $3,236.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.97 / $277.02 / $2,383.14
| Facility | | $204.97 | $277.02 | $2,383.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.55 / $1,702.36 / $3,641.40
| Professional | | $923.55 | $1,702.36 | $3,641.40 |