- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,172.84 / $2,172.84 / $3,462.97
| Facility | | $2,172.84 | $2,172.84 | $3,462.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,069.05 / $2,478.40 / $3,462.97
| Professional | | $2,069.05 | $2,478.40 | $3,462.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,004.57 / $3,004.57 / $3,004.57
| Facility | | $3,004.57 | $3,004.57 | $3,004.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,004.57 / $3,004.57 / $3,004.57
| Professional | | $3,004.57 | $3,004.57 | $3,004.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.75 / $2,326.75 / $2,326.75
| Facility | | $2,326.75 | $2,326.75 | $2,326.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $1,698.53 / $2,326.75
| Professional | | $1,698.53 | $1,698.53 | $2,326.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.77 / $1,803.76 / $3,059.57
| Professional | | $1,145.77 | $1,803.76 | $3,059.57 |