- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,834.97 / $1,834.97 / $2,867.14
| Facility | | $1,834.97 | $1,834.97 | $2,867.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,834.97 / $2,867.14 / $3,307.59
| Professional | | $1,834.97 | $2,867.14 | $3,307.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,537.38 / $2,537.38 / $2,537.38
| Facility | | $2,537.38 | $2,537.38 | $2,537.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,537.38 / $2,537.38 / $2,537.38
| Professional | | $2,537.38 | $2,537.38 | $2,537.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,694.60 / $2,694.60 / $2,694.60
| Facility | | $2,694.60 | $2,694.60 | $2,694.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.06 / $1,967.06 / $3,116.58
| Professional | | $1,967.06 | $1,967.06 | $3,116.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.03 / $1,633.54 / $2,517.23
| Professional | | $1,089.03 | $1,633.54 | $2,517.23 |