- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,653.44 / $2,535.89 / $7,279.41
| Facility | | $1,653.44 | $2,535.89 | $7,279.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,137.48 / $2,539.59
| Professional | | $2,116.32 | $2,137.48 | $2,539.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,292.66 / $2,292.66 / $2,292.66
| Facility | | $2,292.66 | $2,292.66 | $2,292.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,157.15 / $2,292.66 / $2,292.66
| Professional | | $2,157.15 | $2,292.66 | $2,292.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,547.26 / $1,996.53 / $2,116.32
| Facility | | $1,547.26 | $1,996.53 | $2,116.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,116.32
| Professional | | $2,116.32 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.50 / $2,116.32 / $2,116.32
| Professional | | $2,010.50 | $2,116.32 | $2,116.32 |