- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,920.15 / $2,194.46 / $2,233.36
| Facility | | $1,920.15 | $2,194.46 | $2,233.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,920.15 / $2,468.77
| Professional | | $1,828.72 | $1,920.15 | $2,468.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,115.48 / $2,115.48 / $2,115.48
| Facility | | $2,115.48 | $2,115.48 | $2,115.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.71 / $1,828.71 / $2,135.57
| Facility | | $1,828.71 | $1,828.71 | $2,135.57 |
- 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
- $1,755.57 / $1,828.72 / $2,377.34
| Professional | | $1,755.57 | $1,828.72 | $2,377.34 |