- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,864.68 / $1,864.68 / $2,913.57
| Facility | | $1,864.68 | $1,864.68 | $2,913.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.51 / $2,797.03 / $3,140.05
| Professional | | $1,830.51 | $2,797.03 | $3,140.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,578.46 / $2,578.46 / $2,578.46
| Facility | | $2,578.46 | $2,578.46 | $2,578.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.46 / $2,578.46 / $2,578.46
| Professional | | $2,578.46 | $2,578.46 | $2,578.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.11 / $2,425.11 / $2,425.11
| Facility | | $2,425.11 | $2,425.11 | $2,425.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $1,770.33 / $2,425.11
| Professional | | $1,770.33 | $1,770.33 | $2,425.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.24 / $1,660.00 / $2,427.57
| Professional | | $1,050.24 | $1,660.00 | $2,427.57 |