- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,818.38
| Facility | | $2,137.96 | $2,137.96 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,137.96 / $2,137.96
| Professional | | $1,737.80 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $2,041.74 / $2,398.83
| Professional | | $338.84 | $2,041.74 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $831.76
| Facility | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $3,388.44
| Professional | | $2,089.30 | $2,089.30 | $3,388.44 |