- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,796.10 / $2,796.10 / $3,861.29
| Facility | | $2,796.10 | $2,796.10 | $3,861.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.48 / $2,796.10 / $2,796.10
| Professional | | $1,331.48 | $2,796.10 | $2,796.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,442.43 / $1,673.22 / $3,317.59
| Facility | | $1,442.43 | $1,673.22 | $3,317.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,549.86 / $3,187.33
| Professional | | $2,549.86 | $2,549.86 | $3,187.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,997.22 / $1,997.22 / $1,997.22
| Facility | | $1,997.22 | $1,997.22 | $1,997.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $1,331.48 / $2,219.13
| Professional | | $932.03 | $1,331.48 | $2,219.13 |