- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,781.31 / $1,781.31 / $2,783.30
| Facility | | $1,781.31 | $1,781.31 | $2,783.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,672.12 / $2,553.83 / $2,783.30
| Professional | | $1,672.12 | $2,553.83 | $2,783.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.17 / $2,463.17 / $2,463.17
| Facility | | $2,463.17 | $2,463.17 | $2,463.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,463.17 / $2,463.17 / $2,463.17
| Professional | | $2,463.17 | $2,463.17 | $2,463.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.29 / $1,808.29 / $1,808.29
| Facility | | $1,808.29 | $1,808.29 | $1,808.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.05 / $1,537.05 / $2,880.33
| Professional | | $1,537.05 | $1,537.05 | $2,880.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.50 / $1,585.77 / $2,224.76
| Professional | | $962.50 | $1,585.77 | $2,224.76 |