- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,085.82 / $2,784.38 / $2,812.22
| Facility | | $2,085.82 | $2,784.38 | $2,812.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,895.75
| Professional | | $2,784.38 | $2,784.38 | $2,895.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.46 / $1,699.69 / $2,420.94
| Facility | | $1,650.46 | $1,699.69 | $2,420.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Professional | | $2,784.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,626.77 / $2,784.38 / $2,784.38
| Facility | | $2,626.77 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Professional | | $2,784.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.87 / $152.87 / $152.87
| Facility | | $152.87 | $152.87 | $152.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $3,341.26
| Professional | | $2,784.38 | $2,784.38 | $3,341.26 |