- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,311.31
| Facility | | $2,398.83 | $2,398.83 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,621.81 / $2,398.83
| Professional | | $1,258.93 | $1,621.81 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $2,570.40
| Professional | | $1,698.24 | $1,698.24 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,454.71 / $3,548.13
| Facility | | $1,230.27 | $2,454.71 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,905.46
| Facility | | $1,698.24 | $1,698.24 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $1,905.46
| Professional | | $794.33 | $1,148.15 | $1,905.46 |