- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,616.94 / $1,616.94 / $2,526.46
| Facility | | $1,616.94 | $1,616.94 | $2,526.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,616.94 / $2,526.46 / $2,964.61
| Professional | | $1,616.94 | $2,526.46 | $2,964.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,235.89 / $2,235.89 / $2,235.89
| Facility | | $2,235.89 | $2,235.89 | $2,235.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,235.89 / $2,235.89 / $2,235.89
| Professional | | $2,235.89 | $2,235.89 | $2,235.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,289.62 / $2,289.62 / $2,289.62
| Facility | | $2,289.62 | $2,289.62 | $2,289.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.42 / $1,671.42 / $2,746.27
| Professional | | $1,671.42 | $1,671.42 | $2,746.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.63 / $1,439.45 / $2,279.13
| Professional | | $959.63 | $1,439.45 | $2,279.13 |