- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,181.46 / $2,181.46 / $3,408.55
| Facility | | $2,181.46 | $2,181.46 | $3,408.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.56 / $3,042.51 / $3,531.26
| Professional | | $2,058.56 | $3,042.51 | $3,531.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,016.51 / $3,016.51 / $3,016.51
| Facility | | $3,016.51 | $3,016.51 | $3,016.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,016.51 / $3,016.51 / $3,016.51
| Professional | | $3,016.51 | $3,016.51 | $3,016.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,970.85 / $2,970.85 / $2,970.85
| Facility | | $2,970.85 | $2,970.85 | $2,970.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.71 / $2,168.71 / $2,970.85
| Professional | | $2,168.71 | $2,168.71 | $2,970.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.75 / $1,942.01 / $3,074.85
| Professional | | $1,231.75 | $1,942.01 | $3,074.85 |