- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,289.46 / $2,289.46 / $3,577.29
| Facility | | $2,289.46 | $2,289.46 | $3,577.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,149.12 / $3,328.67 / $3,577.29
| Professional | | $2,149.12 | $3,328.67 | $3,577.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,165.84 / $3,165.84 / $3,165.84
| Facility | | $3,165.84 | $3,165.84 | $3,165.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,165.84 / $3,165.84 / $3,165.84
| Professional | | $3,165.84 | $3,165.84 | $3,165.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.71 / $2,282.71 / $2,282.71
| Facility | | $2,282.71 | $2,282.71 | $2,282.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.39 / $1,666.39 / $3,636.05
| Professional | | $1,666.39 | $1,666.39 | $3,636.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.23 / $1,982.23 / $1,982.23
| Facility | | $1,982.23 | $1,982.23 | $1,982.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.02 / $2,038.15 / $2,808.47
| Professional | | $1,215.02 | $2,038.15 | $2,808.47 |