- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,590.54
| Facility | | $1,590.54 | $1,590.54 | $1,590.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,606.45
| Professional | | $1,590.54 | $1,590.54 | $1,606.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.35 / $1,613.43 / $1,747.16
| Professional | | $1,434.35 | $1,613.43 | $1,747.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,961.46 / $2,961.46 / $3,405.68
| Facility | | $2,961.46 | $2,961.46 | $3,405.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,890.94 / $1,909.85 / $2,363.67
| Professional | | $1,890.94 | $1,909.85 | $2,363.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,653.82 / $2,067.35 / $2,862.97
| Facility | | $1,653.82 | $2,067.35 | $2,862.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.82 / $1,653.82 / $1,853.66
| Professional | | $1,653.82 | $1,653.82 | $1,853.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,727.41
| Professional | | $1,590.54 | $1,590.54 | $1,727.41 |