- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,847.00 / $1,861.13 / $1,879.74
| Facility | | $1,847.00 | $1,861.13 | $1,879.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $1,879.74
| Professional | | $1,828.72 | $1,828.72 | $1,879.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.72 / $2,743.08 / $2,743.08
| Facility | | $1,828.72 | $2,743.08 | $2,743.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.20 / $1,828.71 / $3,261.96
| Facility | | $1,725.20 | $1,828.71 | $3,261.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.71 / $1,828.71 / $3,573.86
| Professional | | $1,828.71 | $1,828.71 | $3,573.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,773.86 / $1,828.72 / $3,837.60
| Professional | | $1,773.86 | $1,828.72 | $3,837.60 |