- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,445.21 / $2,445.21 / $2,555.53
| Facility | | $2,445.21 | $2,445.21 | $2,555.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,851.26 / $2,325.91 / $3,107.26
| Professional | | $1,851.26 | $2,325.91 | $3,107.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $552.69 / $883.77 / $1,095.96
| Facility | | $552.69 | $883.77 | $1,095.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.48 / $2,243.69 / $3,016.34
| Professional | | $2,077.48 | $2,243.69 | $3,016.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $2,592.00
| Facility | | $2,592.00 | $2,592.00 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.08 / $2,592.00 / $3,373.90
| Professional | | $296.08 | $2,592.00 | $3,373.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.83 / $1,543.92 / $2,683.96
| Professional | | $1,143.83 | $1,543.92 | $2,683.96 |