- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $4,069.78 / $7,510.89
| Facility | | $2,016.42 | $4,069.78 | $7,510.89 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $1,976.55 / $2,683.27 / $5,162.97
| Professional | | $1,976.55 | $2,683.27 | $5,162.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.29 / $1,902.29 / $2,016.42
| Facility | | $1,902.29 | $1,902.29 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.96 / $1,713.96 / $2,016.42
| Professional | | $1,713.96 | $1,713.96 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,834.94 / $2,016.42 / $2,016.42
| Professional | | $1,834.94 | $2,016.42 | $2,016.42 |