- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,121.31 / $2,121.31 / $2,158.91
| Facility | | $2,121.31 | $2,121.31 | $2,158.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,121.31 / $2,121.31 / $2,121.31
| Professional | | $2,121.31 | $2,121.31 | $2,121.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,081.85 / $2,506.17 / $2,851.29
| Facility | | $2,081.85 | $2,506.17 | $2,851.29 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $3,068.52 / $4,072.42 / $5,493.04
| Facility | | $3,068.52 | $4,072.42 | $5,493.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.28 / $1,828.72 / $1,828.72
| Professional | | $1,737.28 | $1,828.72 | $1,828.72 |