- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,203.06 / $2,203.06 / $3,511.13
| Facility | | $2,203.06 | $2,203.06 | $3,511.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,852.19 / $2,512.86 / $3,511.13
| Professional | | $1,852.19 | $2,512.86 | $3,511.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,046.37 / $3,046.37 / $3,046.37
| Facility | | $3,046.37 | $3,046.37 | $3,046.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,046.37 / $3,046.37 / $3,046.37
| Professional | | $3,046.37 | $3,046.37 | $3,046.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,017.28 / $2,017.28 / $2,017.28
| Facility | | $2,017.28 | $2,017.28 | $2,017.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.61 / $1,472.61 / $2,017.28
| Professional | | $1,472.61 | $1,472.61 | $2,017.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.74 / $1,828.86 / $2,927.54
| Professional | | $1,073.74 | $1,828.86 | $2,927.54 |