- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,089.16 / $2,130.53
| Facility | | $2,068.46 | $2,089.16 | $2,130.53 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $2,991.60 / $2,991.60 / $4,487.39
| Facility | | $2,991.60 | $2,991.60 | $4,487.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,991.60 / $2,991.60 / $3,051.43
| Professional | | $2,991.60 | $2,991.60 | $3,051.43 |
- 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
- $1,951.39 / $1,951.39 / $2,068.46
| Facility | | $1,951.39 | $1,951.39 | $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
- $1,965.38 / $2,068.46 / $2,585.59
| Professional | | $1,965.38 | $2,068.46 | $2,585.59 |