- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,722.16 / $2,722.16 / $2,775.98
| Facility | | $2,722.16 | $2,722.16 | $2,775.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,051.69 / $2,671.03 / $3,359.31
| Professional | | $2,051.69 | $2,671.03 | $3,359.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.02 / $2,517.12 / $2,517.12
| Facility | | $2,104.02 | $2,517.12 | $2,517.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,079.98 / $2,079.98 / $3,267.36
| Professional | | $2,079.98 | $2,079.98 | $3,267.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.69 / $2,290.69 / $3,236.31
| Facility | | $2,290.69 | $2,290.69 | $3,236.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.10 / $2,290.69 / $3,236.31
| Professional | | $1,947.10 | $2,290.69 | $3,236.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.97 / $319.47 / $2,829.98
| Facility | | $204.97 | $319.47 | $2,829.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.40 / $1,749.60 / $3,158.80
| Professional | | $1,364.40 | $1,749.60 | $3,158.80 |