- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,203.67 / $2,203.67 / $2,218.41
| Facility | | $2,203.67 | $2,203.67 | $2,218.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.65 / $2,061.32 / $2,689.49
| Professional | | $1,723.65 | $2,061.32 | $2,689.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $551.05 / $551.05 / $551.05
| Facility | | $551.05 | $551.05 | $551.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,850.80 / $1,893.62 / $2,376.16
| Professional | | $1,850.80 | $1,893.62 | $2,376.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,387.48 / $2,387.48 / $2,387.48
| Facility | | $2,387.48 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.33 / $2,387.48 / $2,430.00
| Professional | | $284.33 | $2,387.48 | $2,430.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.27 / $1,237.94 / $2,178.40
| Professional | | $952.27 | $1,237.94 | $2,178.40 |