- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,694.36 / $1,694.36 / $2,647.43
| Facility | | $1,694.36 | $1,694.36 | $2,647.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.48 / $2,427.15 / $2,647.43
| Professional | | $1,590.48 | $2,427.15 | $2,647.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,342.92 / $2,342.92 / $2,342.92
| Facility | | $2,342.92 | $2,342.92 | $2,342.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,342.92 / $2,342.92 / $2,342.92
| Professional | | $2,342.92 | $2,342.92 | $2,342.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.78 / $1,902.78 / $1,902.78
| Facility | | $1,902.78 | $1,902.78 | $1,902.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.03 / $1,389.03 / $1,902.78
| Professional | | $1,389.03 | $1,389.03 | $1,902.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.30 / $1,508.36 / $2,385.81
| Professional | | $978.30 | $1,508.36 | $2,385.81 |