- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,774.04 / $2,774.04 / $3,830.82
| Facility | | $2,774.04 | $2,774.04 | $3,830.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.97 / $2,774.04 / $2,774.04
| Professional | | $1,320.97 | $2,774.04 | $2,774.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,431.05 / $1,660.02 / $2,876.41
| Facility | | $1,431.05 | $1,660.02 | $2,876.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.63 / $2,529.63 / $3,162.03
| Professional | | $2,529.63 | $2,529.63 | $3,162.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.46 / $1,981.46 / $1,981.46
| Facility | | $1,981.46 | $1,981.46 | $1,981.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.68 / $1,320.97 / $2,201.62
| Professional | | $924.68 | $1,320.97 | $2,201.62 |