- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,226.63 / $2,226.63 / $3,479.11
| Facility | | $2,226.63 | $2,226.63 | $3,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.14 / $3,192.32 / $3,479.11
| Professional | | $2,090.14 | $3,192.32 | $3,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,078.96 / $3,078.96 / $3,078.96
| Facility | | $3,078.96 | $3,078.96 | $3,078.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,078.96 / $3,078.96 / $3,078.96
| Professional | | $3,078.96 | $3,078.96 | $3,078.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,214.74 / $3,214.74 / $3,214.74
| Facility | | $3,214.74 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.53 / $2,732.53 / $3,214.74
| Professional | | $2,732.53 | $2,732.53 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.11 / $1,982.21 / $2,780.96
| Professional | | $1,203.11 | $1,982.21 | $2,780.96 |