- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,680.32 / $2,680.32 / $2,730.98
| Facility | | $2,680.32 | $2,680.32 | $2,730.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,047.10 / $2,589.60 / $3,237.94
| Professional | | $2,047.10 | $2,589.60 | $3,237.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $751.95 / $751.95 / $751.95
| Facility | | $751.95 | $751.95 | $751.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.01 / $2,852.72 / $3,157.12
| Professional | | $2,344.01 | $2,852.72 | $3,157.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.45 / $2,671.66 / $3,280.69
| Professional | | $318.45 | $2,671.66 | $3,280.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.25 / $1,588.21 / $2,766.93
| Professional | | $1,217.25 | $1,588.21 | $2,766.93 |