- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,359.92 / $2,359.92 / $3,687.39
| Facility | | $2,359.92 | $2,359.92 | $3,687.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.73 / $3,431.10 / $3,943.24
| Professional | | $2,298.73 | $3,431.10 | $3,943.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,263.29 / $3,263.29 / $3,263.29
| Facility | | $3,263.29 | $3,263.29 | $3,263.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,263.29 / $3,263.29 / $3,263.29
| Professional | | $3,263.29 | $3,263.29 | $3,263.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,364.97 / $3,364.97 / $3,364.97
| Facility | | $3,364.97 | $3,364.97 | $3,364.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.42 / $2,456.42 / $3,364.97
| Professional | | $2,456.42 | $2,456.42 | $3,364.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.02 / $2,100.88 / $3,127.45
| Professional | | $1,353.02 | $2,100.88 | $3,127.45 |