- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,615.05 / $1,615.05 / $2,523.51
| Facility | | $1,615.05 | $1,615.05 | $2,523.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,615.05 / $2,425.64 / $2,829.20
| Professional | | $1,615.05 | $2,425.64 | $2,829.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,233.29 / $2,233.29 / $2,233.29
| Facility | | $2,233.29 | $2,233.29 | $2,233.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.29 / $2,233.29 / $2,233.29
| Professional | | $2,233.29 | $2,233.29 | $2,233.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,084.13 / $2,084.13 / $2,084.13
| Facility | | $2,084.13 | $2,084.13 | $2,084.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,521.41 / $1,521.41 / $2,084.13
| Professional | | $1,521.41 | $1,521.41 | $2,084.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.91 / $1,815.91 / $2,117.59
| Facility | | $1,815.91 | $1,815.91 | $2,117.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.13 / $1,437.76 / $2,117.59
| Professional | | $916.13 | $1,437.76 | $2,117.59 |