- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,822.70 / $1,822.70 / $2,303.00
| Facility | | $1,822.70 | $1,822.70 | $2,303.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,773.55 / $1,825.83 / $2,036.46
| Professional | | $1,773.55 | $1,825.83 | $2,036.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,405.83 / $1,405.83 / $1,722.14
| Facility | | $1,405.83 | $1,405.83 | $1,722.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.51 / $1,230.09 / $1,581.56
| Professional | | $966.51 | $1,230.09 | $1,581.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,373.25 / $2,373.25 / $2,984.18
| Professional | | $2,373.25 | $2,373.25 | $2,984.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,796.21 / $1,940.65 / $2,972.41
| Facility | | $1,796.21 | $1,940.65 | $2,972.41 |