- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,089.16 / $2,220.57
| Facility | | $2,068.46 | $2,089.16 | $2,220.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,171.90
| Professional | | $2,068.46 | $2,068.46 | $2,171.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $3,992.15
| Facility | | $2,068.46 | $2,068.46 | $3,992.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,109.83
| Professional | | $2,068.46 | $2,068.46 | $2,109.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,951.39 / $2,068.46 / $2,068.46
| Facility | | $1,951.39 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,068.46
| Professional | | $2,068.46 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,482.16
| Professional | | $2,068.46 | $2,068.46 | $2,482.16 |