- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,515.31 / $1,515.31 / $2,367.67
| Facility | | $1,515.31 | $1,515.31 | $2,367.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.12 / $2,272.96 / $2,606.63
| Professional | | $1,487.12 | $2,272.96 | $2,606.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,095.35 / $2,095.35 / $2,095.35
| Facility | | $2,095.35 | $2,095.35 | $2,095.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,095.35 / $2,095.35 / $2,095.35
| Professional | | $2,095.35 | $2,095.35 | $2,095.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,119.51 / $2,119.51 / $2,119.51
| Facility | | $2,119.51 | $2,119.51 | $2,119.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.24 / $1,547.24 / $2,119.51
| Professional | | $1,547.24 | $1,547.24 | $2,119.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.06 / $1,348.97 / $2,135.87
| Professional | | $835.06 | $1,348.97 | $2,135.87 |