- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.76 / $2,337.76 / $2,697.42
| Professional | | $2,337.76 | $2,337.76 | $2,697.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.06 / $2,853.06 / $3,521.03
| Facility | | $2,853.06 | $2,853.06 | $3,521.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,853.06 / $2,938.65
| Professional | | $2,082.73 | $2,853.06 | $2,938.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.06 / $2,853.06 / $3,521.03
| Facility | | $2,853.06 | $2,853.06 | $3,521.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,853.06 / $2,938.65
| Professional | | $2,082.73 | $2,853.06 | $2,938.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,593.32 / $3,432.08 / $5,538.16
| Professional | | $1,593.32 | $3,432.08 | $5,538.16 |