- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $3,019.95
| Facility | | $2,187.76 | $2,187.76 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $2,187.76
| Professional | | $1,047.13 | $1,479.11 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,691.53
| Facility | | $1,995.26 | $1,995.26 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,344.23
| Professional | | $1,548.82 | $1,548.82 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,238.72 / $3,235.94
| Facility | | $1,122.02 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,737.80
| Facility | | $1,548.82 | $1,548.82 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $1,737.80
| Professional | | $724.44 | $1,047.13 | $1,737.80 |