- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,109.40 / $2,109.40 / $3,295.93
| Facility | | $2,109.40 | $2,109.40 | $3,295.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.08 / $3,066.84 / $3,295.93
| Professional | | $1,980.08 | $3,066.84 | $3,295.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,916.83 / $2,916.83 / $2,916.83
| Facility | | $2,916.83 | $2,916.83 | $2,916.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,916.83 / $2,916.83 / $2,916.83
| Professional | | $2,916.83 | $2,916.83 | $2,916.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,264.80 / $2,264.80 / $2,264.80
| Facility | | $2,264.80 | $2,264.80 | $2,264.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.30 / $1,653.30 / $2,264.80
| Professional | | $1,653.30 | $1,653.30 | $2,264.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.32 / $1,838.65 / $2,571.06
| Professional | | $1,112.32 | $1,838.65 | $2,571.06 |