- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.72 / $1,981.72 / $3,096.44
| Facility | | $1,981.72 | $1,981.72 | $3,096.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.24 / $2,841.16 / $3,096.44
| Professional | | $1,860.24 | $2,841.16 | $3,096.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,740.29 / $2,740.29 / $2,740.29
| Facility | | $2,740.29 | $2,740.29 | $2,740.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,740.29 / $2,740.29 / $2,740.29
| Professional | | $2,740.29 | $2,740.29 | $2,740.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,861.13 / $2,861.13 / $2,861.13
| Facility | | $2,861.13 | $2,861.13 | $2,861.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.96 / $2,431.96 / $2,861.13
| Professional | | $2,431.96 | $2,431.96 | $2,861.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.78 / $1,764.18 / $2,475.06
| Professional | | $1,070.78 | $1,764.18 | $2,475.06 |