- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,963.16 / $1,963.16 / $3,067.43
| Facility | | $1,963.16 | $1,963.16 | $3,067.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,963.16 / $2,949.38 / $3,602.89
| Professional | | $1,963.16 | $2,949.38 | $3,602.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.62 / $2,714.62 / $2,714.62
| Facility | | $2,714.62 | $2,714.62 | $2,714.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,714.62 / $2,714.62 / $2,714.62
| Professional | | $2,714.62 | $2,714.62 | $2,714.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,782.58 / $2,782.58 / $2,782.58
| Facility | | $2,782.58 | $2,782.58 | $2,782.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.28 / $2,031.28 / $3,334.30
| Professional | | $2,031.28 | $2,031.28 | $3,334.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.32 / $1,747.65 / $2,608.07
| Professional | | $1,128.32 | $1,747.65 | $2,608.07 |