- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $3,350.03
| Facility | | $1,828.72 | $1,828.72 | $3,350.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $2,251.96
| Professional | | $1,828.72 | $1,828.72 | $2,251.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,983.98 / $1,993.90 / $2,019.49
| Facility | | $1,983.98 | $1,993.90 | $2,019.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,686.38 / $1,990.92 / $2,008.78
| Professional | | $1,686.38 | $1,990.92 | $2,008.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,788.94 / $1,806.83 / $2,236.17
| Professional | | $1,788.94 | $1,806.83 | $2,236.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.13 / $2,076.46 / $3,837.60
| Facility | | $1,861.13 | $2,076.46 | $3,837.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.81 / $1,861.13 / $2,021.28
| Professional | | $1,755.81 | $1,861.13 | $2,021.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.41 / $1,828.72 / $2,048.17
| Professional | | $1,554.41 | $1,828.72 | $2,048.17 |