- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,491.98 / $2,491.98 / $3,893.72
| Facility | | $2,491.98 | $2,491.98 | $3,893.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,339.23 / $3,623.10 / $3,893.72
| Professional | | $2,339.23 | $3,623.10 | $3,893.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,445.88 / $3,445.88 / $3,445.88
| Facility | | $3,445.88 | $3,445.88 | $3,445.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,445.88 / $3,445.88 / $3,445.88
| Professional | | $3,445.88 | $3,445.88 | $3,445.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,060.59 / $3,060.59 / $3,060.59
| Facility | | $3,060.59 | $3,060.59 | $3,060.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.23 / $2,234.23 / $3,932.45
| Professional | | $2,234.23 | $2,234.23 | $3,932.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.07 / $2,218.42 / $3,285.18
| Professional | | $1,314.07 | $2,218.42 | $3,285.18 |