- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.06 / $2,454.06 / $2,571.17
| Facility | | $2,454.06 | $2,454.06 | $2,571.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.60 / $2,425.35 / $2,977.94
| Professional | | $1,863.60 | $2,425.35 | $2,977.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,015.43 / $3,372.82 / $3,372.82
| Facility | | $2,015.43 | $3,372.82 | $3,372.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,303.88 / $2,655.12 / $3,041.68
| Professional | | $2,303.88 | $2,655.12 | $3,041.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,254.90 / $2,254.90 / $2,254.90
| Facility | | $2,254.90 | $2,254.90 | $2,254.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.95 / $2,254.90 / $3,230.73
| Professional | | $295.95 | $2,254.90 | $3,230.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.50 / $1,559.88 / $2,633.68
| Professional | | $1,071.50 | $1,559.88 | $2,633.68 |