- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,140.30 / $2,194.46 / $3,698.05
| Facility | | $2,140.30 | $2,194.46 | $3,698.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $2,194.46 / $2,233.36
| Professional | | $1,828.72 | $2,194.46 | $2,233.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,019.16 / $2,019.16 / $2,019.16
| Facility | | $2,019.16 | $2,019.16 | $2,019.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.07 / $2,019.16 / $2,019.16
| Professional | | $1,822.07 | $2,019.16 | $2,019.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.20 / $1,828.71 / $3,023.05
| Facility | | $1,725.20 | $1,828.71 | $3,023.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.71 / $1,828.71 / $1,828.71
| Professional | | $1,828.71 | $1,828.71 | $1,828.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $3,261.96
| Professional | | $1,828.72 | $1,828.72 | $3,261.96 |