- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,615.51 / $2,615.51 / $3,611.89
| Facility | | $2,615.51 | $2,615.51 | $3,611.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.48 / $2,615.51 / $2,615.51
| Professional | | $1,245.48 | $2,615.51 | $2,615.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,349.27 / $1,565.15 / $2,712.03
| Facility | | $1,349.27 | $1,565.15 | $2,712.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,385.08 / $2,385.08 / $2,981.34
| Professional | | $2,385.08 | $2,385.08 | $2,981.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,868.22 / $1,868.22 / $1,868.22
| Facility | | $1,868.22 | $1,868.22 | $1,868.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $1,245.48 / $2,075.80
| Professional | | $871.84 | $1,245.48 | $2,075.80 |