- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,351.55 / $2,351.55 / $2,713.33
| Professional | | $2,351.55 | $2,351.55 | $2,713.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $2,756.64
| Facility | | $2,756.64 | $2,756.64 | $2,756.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $2,012.35
| Professional | | $2,012.35 | $2,012.35 | $2,012.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $2,756.64
| Facility | | $2,756.64 | $2,756.64 | $2,756.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $2,012.35
| Professional | | $2,012.35 | $2,012.35 | $2,012.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.71 / $2,854.53 / $5,570.82
| Professional | | $1,602.71 | $2,854.53 | $5,570.82 |