- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,336.66 / $2,336.66 / $3,651.03
| Facility | | $2,336.66 | $2,336.66 | $3,651.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,269.59 / $3,397.60 / $3,893.24
| Professional | | $2,269.59 | $3,397.60 | $3,893.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,231.11 / $3,231.11 / $3,231.11
| Facility | | $3,231.11 | $3,231.11 | $3,231.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,231.11 / $3,231.11 / $3,231.11
| Professional | | $3,231.11 | $3,231.11 | $3,231.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,006.81 / $3,006.81 / $3,006.81
| Facility | | $3,006.81 | $3,006.81 | $3,006.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.96 / $2,194.96 / $3,006.81
| Professional | | $2,194.96 | $2,194.96 | $3,006.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.78 / $2,080.16 / $3,205.46
| Professional | | $1,386.78 | $2,080.16 | $3,205.46 |