- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,165.46 / $2,165.46 / $2,498.61
| Professional | | $2,165.46 | $2,165.46 | $2,498.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $2,941.06
| Facility | | $2,941.06 | $2,941.06 | $2,941.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $2,146.96
| Professional | | $2,146.96 | $2,146.96 | $2,146.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $2,941.06
| Facility | | $2,941.06 | $2,941.06 | $2,941.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $2,146.96
| Professional | | $2,146.96 | $2,146.96 | $2,146.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,534.92 / $2,628.63 / $5,129.97
| Professional | | $1,534.92 | $2,628.63 | $5,129.97 |