- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,196.94 / $3,237.66 / $3,399.54
| Facility | | $3,196.94 | $3,237.66 | $3,399.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,832.96 / $3,237.66
| Professional | | $2,698.05 | $2,832.96 | $3,237.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,927.13 / $2,927.13 / $2,927.13
| Facility | | $2,927.13 | $2,927.13 | $2,927.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,758.44 / $2,927.13 / $2,927.13
| Professional | | $2,758.44 | $2,927.13 | $2,927.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,429.44 / $2,658.13 / $2,698.05
| Facility | | $2,429.44 | $2,658.13 | $2,698.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,927.13
| Professional | | $2,698.05 | $2,698.05 | $2,927.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $3,102.76
| Professional | | $2,698.05 | $2,698.05 | $3,102.76 |