- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,952.67 / $1,952.67 / $3,051.05
| Facility | | $1,952.67 | $1,952.67 | $3,051.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.39 / $2,769.45 / $3,329.94
| Professional | | $1,844.39 | $2,769.45 | $3,329.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,700.13 / $2,700.13 / $2,700.13
| Facility | | $2,700.13 | $2,700.13 | $2,700.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,700.13 / $2,700.13 / $2,700.13
| Professional | | $2,700.13 | $2,700.13 | $2,700.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.77 / $2,571.77 / $2,571.77
| Facility | | $2,571.77 | $2,571.77 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $1,877.39 / $2,571.77
| Professional | | $1,877.39 | $1,877.39 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.36 / $1,738.33 / $2,369.16
| Professional | | $1,021.36 | $1,738.33 | $2,369.16 |