- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,972.70 / $4,350.29 / $4,350.29
| Facility | | $2,972.70 | $4,350.29 | $4,350.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.70 / $3,081.45 / $4,350.29
| Professional | | $2,972.70 | $3,081.45 | $4,350.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,084.73 / $2,084.73 / $2,293.21
| Facility | | $2,084.73 | $2,084.73 | $2,293.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,532.10 / $3,081.45 / $3,081.45
| Facility | | $2,532.10 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,900.20 / $3,021.04 / $3,927.35
| Professional | | $2,900.20 | $3,021.04 | $3,927.35 |