- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,976.55 / $1,976.55 / $4,069.78
| Facility | | $1,976.55 | $1,976.55 | $4,069.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,318.88
| Professional | | $2,016.42 | $2,016.42 | $2,318.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,976.55 / $1,976.55 / $2,016.43
| Professional | | $1,976.55 | $1,976.55 | $2,016.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,568.09
| Professional | | $2,016.42 | $2,016.42 | $2,568.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,286.73
| Professional | | $2,016.42 | $2,016.42 | $2,286.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,137.41
| Professional | | $2,016.42 | $2,016.42 | $2,137.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,931.81 / $1,931.81 / $1,931.81
| Professional | | $1,931.81 | $1,931.81 | $1,931.81 |