- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,976.55 / $2,075.38 / $4,368.18
| Facility | | $1,976.55 | $2,075.38 | $4,368.18 |
- 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
- $1,381.71 / $1,621.21 / $2,117.75
| Facility | | $1,381.71 | $1,621.21 | $2,117.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.75 / $2,117.75 / $2,160.11
| Professional | | $2,117.75 | $2,117.75 | $2,160.11 |
- 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
- $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
- $2,016.42 / $2,016.42 / $2,540.81
| Professional | | $2,016.42 | $2,016.42 | $2,540.81 |