- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,210.75 / $3,210.75 / $3,300.39
| Facility | | $3,210.75 | $3,210.75 | $3,300.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,440.39 / $3,138.47 / $4,098.01
| Professional | | $2,440.39 | $3,138.47 | $4,098.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $899.87 / $1,273.32 / $1,868.28
| Facility | | $899.87 | $1,273.32 | $1,868.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,715.41 / $3,066.27 / $3,880.32
| Professional | | $2,715.41 | $3,066.27 | $3,880.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $3,349.85
| Facility | | $3,349.85 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.28 / $3,349.85 / $3,547.80
| Professional | | $399.28 | $3,349.85 | $3,547.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,451.10 / $1,986.72 / $3,344.53
| Professional | | $1,451.10 | $1,986.72 | $3,344.53 |