- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.48 / $2,147.48 / $3,355.44
| Facility | | $2,147.48 | $2,147.48 | $3,355.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,129.71 / $3,122.22 / $3,355.44
| Professional | | $2,129.71 | $3,122.22 | $3,355.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,969.51 / $2,969.51 / $2,969.51
| Facility | | $2,969.51 | $2,969.51 | $2,969.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,969.51 / $2,969.51 / $2,969.51
| Professional | | $2,969.51 | $2,969.51 | $2,969.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,381.07 / $2,381.07 / $2,381.07
| Facility | | $2,381.07 | $2,381.07 | $2,381.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.18 / $1,738.18 / $2,381.07
| Professional | | $1,738.18 | $1,738.18 | $2,381.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.68 / $1,914.86 / $2,945.94
| Professional | | $1,132.68 | $1,914.86 | $2,945.94 |