- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,095.74 / $3,095.74 / $3,182.31
| Facility | | $3,095.74 | $3,095.74 | $3,182.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,352.98 / $3,047.37 / $3,951.24
| Professional | | $2,352.98 | $3,047.37 | $3,951.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.71 / $1,227.64 / $1,801.44
| Facility | | $867.71 | $1,227.64 | $1,801.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,617.98 / $2,956.33 / $3,741.70
| Professional | | $2,617.98 | $2,956.33 | $3,741.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $2,673.00
| Facility | | $2,673.00 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.96 / $2,673.00 / $3,931.29
| Professional | | $384.96 | $2,673.00 | $3,931.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.14 / $1,872.66 / $3,245.92
| Professional | | $1,399.14 | $1,872.66 | $3,245.92 |