- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,145.34 / $2,145.34 / $3,352.09
| Facility | | $2,145.34 | $2,145.34 | $3,352.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,013.83 / $3,119.09 / $3,352.09
| Professional | | $2,013.83 | $3,119.09 | $3,352.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,966.54 / $2,966.54 / $2,966.54
| Facility | | $2,966.54 | $2,966.54 | $2,966.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,966.54 / $2,966.54 / $2,966.54
| Professional | | $2,966.54 | $2,966.54 | $2,966.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.07 / $2,463.07 / $2,463.07
| Facility | | $2,463.07 | $2,463.07 | $2,463.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.04 / $1,798.04 / $2,463.07
| Professional | | $1,798.04 | $1,798.04 | $2,463.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.27 / $1,909.84 / $2,614.89
| Professional | | $1,131.27 | $1,909.84 | $2,614.89 |