- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,931.06 / $1,931.06 / $3,017.28
| Facility | | $1,931.06 | $1,931.06 | $3,017.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.69 / $2,807.57 / $3,017.28
| Professional | | $1,812.69 | $2,807.57 | $3,017.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,670.25 / $2,670.25 / $2,670.25
| Facility | | $2,670.25 | $2,670.25 | $2,670.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.25 / $2,670.25 / $2,670.25
| Professional | | $2,670.25 | $2,670.25 | $2,670.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.07 / $2,217.07 / $2,217.07
| Facility | | $2,217.07 | $2,217.07 | $2,217.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.46 / $1,618.46 / $2,217.07
| Professional | | $1,618.46 | $1,618.46 | $2,217.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,018.42 / $2,018.42 / $2,353.73
| Facility | | $2,018.42 | $2,018.42 | $2,353.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.29 / $1,719.08 / $2,353.73
| Professional | | $1,018.29 | $1,719.08 | $2,353.73 |