- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,151.21 / $2,151.21 / $3,613.04
| Facility | | $2,151.21 | $2,151.21 | $3,613.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,089.16 / $2,275.32
| Professional | | $2,068.46 | $2,089.16 | $2,275.32 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,068.46
| Facility | | $2,068.46 | $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
- $2,146.53 / $2,146.53 / $2,587.54
| Professional | | $2,146.53 | $2,146.53 | $2,587.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,965.05 / $2,068.46 / $2,171.89
| Professional | | $1,965.05 | $2,068.46 | $2,171.89 |