- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,550.74 / $2,550.74 / $2,700.86
| Facility | | $2,550.74 | $2,550.74 | $2,700.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.58 / $2,406.10 / $3,196.17
| Professional | | $1,800.58 | $2,406.10 | $3,196.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,565.17 / $2,565.17 / $2,565.17
| Facility | | $2,565.17 | $2,565.17 | $2,565.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,513.84 / $2,908.80 / $3,033.82
| Professional | | $2,513.84 | $2,908.80 | $3,033.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,399.94 / $2,399.94 / $2,821.87
| Facility | | $2,399.94 | $2,399.94 | $2,821.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.90 / $2,399.94 / $3,349.92
| Professional | | $355.90 | $2,399.94 | $3,349.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,562.20 / $2,042.34 / $3,392.70
| Professional | | $1,562.20 | $2,042.34 | $3,392.70 |