- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,896.59 / $2,896.59 / $2,896.59
| Facility | | $2,896.59 | $2,896.59 | $2,896.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.14 / $2,896.59 / $2,896.59
| Professional | | $1,471.14 | $2,896.59 | $2,896.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,564.69 / $2,564.69 / $2,564.69
| Professional | | $2,564.69 | $2,564.69 | $2,564.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.07 / $2,217.07 / $3,427.30
| Facility | | $2,217.07 | $2,217.07 | $3,427.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.46 / $2,217.07 / $3,001.06
| Professional | | $1,618.46 | $2,217.07 | $3,001.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,018.42 / $2,291.16 / $2,353.73
| Facility | | $2,018.42 | $2,291.16 | $2,353.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.29 / $1,719.08 / $2,366.61
| Professional | | $1,018.29 | $1,719.08 | $2,366.61 |