- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,761.98 / $2,761.98 / $2,867.42
| Facility | | $2,761.98 | $2,761.98 | $2,867.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.59 / $2,739.49 / $3,520.57
| Professional | | $2,191.59 | $2,739.49 | $3,520.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $854.90 / $1,143.50 / $1,719.87
| Facility | | $854.90 | $1,143.50 | $1,719.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.86 / $2,231.25 / $3,351.76
| Professional | | $2,230.86 | $2,231.25 | $3,351.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,792.28
| Facility | | $2,446.40 | $2,446.40 | $2,792.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.08 / $2,446.40 / $3,331.31
| Professional | | $321.08 | $2,446.40 | $3,331.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.76 / $1,798.88 / $3,145.73
| Professional | | $1,266.76 | $1,798.88 | $3,145.73 |