- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,361.56 / $2,361.56 / $3,689.94
| Facility | | $2,361.56 | $2,361.56 | $3,689.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,216.80 / $3,689.94 / $4,578.39
| Professional | | $2,216.80 | $3,689.94 | $4,578.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,265.54 / $3,265.54 / $3,265.54
| Facility | | $3,265.54 | $3,265.54 | $3,265.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,265.54 / $3,265.54 / $3,265.54
| Professional | | $3,265.54 | $3,265.54 | $3,265.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $2,741.63
| Facility | | $2,741.63 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,001.39 / $2,741.63
| Professional | | $2,001.39 | $2,001.39 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.55 / $2,102.33 / $3,328.69
| Professional | | $1,401.55 | $2,102.33 | $3,328.69 |