- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,928.07 / $2,928.07 / $4,575.10
| Facility | | $2,928.07 | $2,928.07 | $4,575.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,827.06 / $4,257.17 / $4,849.53
| Professional | | $2,827.06 | $4,257.17 | $4,849.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,048.90 / $4,048.90 / $4,048.90
| Facility | | $4,048.90 | $4,048.90 | $4,048.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,048.90 / $4,048.90 / $4,048.90
| Professional | | $4,048.90 | $4,048.90 | $4,048.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.37 / $3,745.37 / $3,745.37
| Facility | | $3,745.37 | $3,745.37 | $3,745.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.12 / $2,734.12 / $4,973.14
| Professional | | $2,734.12 | $2,734.12 | $4,973.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.35 / $2,606.65 / $4,008.86
| Professional | | $1,734.35 | $2,606.65 | $4,008.86 |