- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,388.44
| Facility | | $2,454.71 | $2,454.71 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,659.59 / $2,454.71
| Professional | | $1,174.90 | $1,659.59 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,630.27
| Professional | | $1,995.26 | $1,995.26 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,511.89 / $3,630.78
| Facility | | $1,258.93 | $2,511.89 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,949.84
| Facility | | $1,737.80 | $1,737.80 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $1,949.84
| Professional | | $812.83 | $1,174.90 | $1,949.84 |