- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,767.04 / $4,498.52
| Facility | | $2,016.42 | $2,767.04 | $4,498.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,036.58 / $2,391.63
| Professional | | $2,016.42 | $2,036.58 | $2,391.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $3,355.32 / $6,411.20
| Facility | | $2,016.42 | $3,355.32 | $6,411.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.29 / $2,016.42 / $2,016.42
| Facility | | $1,902.29 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Facility | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,189.92
| Professional | | $2,016.42 | $2,016.42 | $2,189.92 |