- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,754.12 / $1,988.00 / $2,551.44
| Facility | | $1,754.12 | $1,988.00 | $2,551.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.55 / $1,747.55 / $2,919.91
| Professional | | $1,747.55 | $1,747.55 | $2,919.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,551.44 / $2,551.44 / $2,551.44
| Professional | | $2,551.44 | $2,551.44 | $2,551.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,003.75 / $2,402.61 / $2,657.75
| Professional | | $2,003.75 | $2,402.61 | $2,657.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,338.82 / $2,551.44 / $2,976.68
| Professional | | $2,338.82 | $2,551.44 | $2,976.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.19 / $2,551.44 / $3,189.30
| Professional | | $2,126.19 | $2,551.44 | $3,189.30 |