- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.97 / $1,078.97 / $1,078.97
| Facility | | $1,078.97 | $1,078.97 | $1,078.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.97 / $1,277.72 / $1,770.76
| Professional | | $1,078.97 | $1,277.72 | $1,770.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,782.28 / $2,084.13 / $2,936.08
| Facility | | $1,782.28 | $2,084.13 | $2,936.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,521.41 / $1,521.41 / $2,570.94
| Professional | | $1,521.41 | $1,521.41 | $2,570.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,682.33 / $2,701.19 / $3,846.26
| Professional | | $2,682.33 | $2,701.19 | $3,846.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.94 / $2,867.27 / $2,936.08
| Professional | | $2,570.94 | $2,867.27 | $2,936.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.91 / $2,070.03 / $2,936.08
| Facility | | $1,815.91 | $2,070.03 | $2,936.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.89 / $1,464.78 / $2,695.47
| Professional | | $1,323.89 | $1,464.78 | $2,695.47 |