- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.75 / $1,997.66 / $2,084.52
| Facility | | $1,201.75 | $1,997.66 | $2,084.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,747.63 / $2,076.39
| Professional | | $1,730.32 | $1,747.63 | $2,076.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,051.55 / $2,051.55 / $2,051.55
| Facility | | $2,051.55 | $2,051.55 | $2,051.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.33 / $2,051.55 / $2,051.55
| Professional | | $1,733.33 | $2,051.55 | $2,051.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.03 / $1,632.38 / $1,730.32
| Facility | | $758.03 | $1,632.38 | $1,730.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,730.32
| Professional | | $1,730.32 | $1,730.32 | $1,730.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,643.80 / $1,831.33 / $2,214.81
| Professional | | $1,643.80 | $1,831.33 | $2,214.81 |