- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $4,365.16
| Facility | | $3,162.28 | $3,162.28 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $3,162.28
| Professional | | $1,513.56 | $2,137.96 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,890.45
| Facility | | $2,818.38 | $2,818.38 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $3,388.44
| Professional | | $2,238.72 | $2,238.72 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,235.94 / $4,677.35
| Facility | | $1,621.81 | $3,235.94 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,511.89
| Facility | | $2,238.72 | $2,238.72 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $3,388.44
| Professional | | $1,047.13 | $1,513.56 | $3,388.44 |