- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,369.42 / $2,369.42 / $3,702.22
| Facility | | $2,369.42 | $2,369.42 | $3,702.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,224.19 / $3,115.17 / $4,269.50
| Professional | | $2,224.19 | $3,115.17 | $4,269.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,276.41 / $3,276.41 / $3,276.41
| Facility | | $3,276.41 | $3,276.41 | $3,276.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,276.41 / $3,276.41 / $3,276.41
| Professional | | $3,276.41 | $3,276.41 | $3,276.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,297.39 / $3,297.39 / $3,297.39
| Facility | | $3,297.39 | $3,297.39 | $3,297.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.09 / $2,407.09 / $3,297.39
| Professional | | $2,407.09 | $2,407.09 | $3,297.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.50 / $2,274.02 / $3,339.76
| Professional | | $1,271.50 | $2,274.02 | $3,339.76 |