- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,921.65 / $1,959.70
| Facility | | $1,902.62 | $1,921.65 | $1,959.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,921.65 / $2,092.88
| Professional | | $1,902.62 | $1,921.65 | $2,092.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,584.91 / $2,584.91 / $3,877.37
| Facility | | $2,584.91 | $2,584.91 | $3,877.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,584.91 / $2,584.91 / $2,636.61
| Professional | | $2,584.91 | $2,584.91 | $2,636.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.37 / $121.37 / $121.37
| Facility | | $121.37 | $121.37 | $121.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.93 / $1,794.93 / $1,902.62
| Facility | | $1,794.93 | $1,794.93 | $1,902.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Professional | | $1,902.62 | $1,902.62 | $1,902.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.79 / $1,902.62 / $2,321.19
| Professional | | $1,807.79 | $1,902.62 | $2,321.19 |