- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,117.23 / $2,371.86 / $2,419.71
| Facility | | $2,117.23 | $2,371.86 | $2,419.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,117.23 / $2,419.71
| Professional | | $2,016.42 | $2,117.23 | $2,419.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,516.80 / $1,516.80 / $1,668.48
| Facility | | $1,516.80 | $1,516.80 | $1,668.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,318.17
| Facility | | $2,016.42 | $2,016.42 | $2,318.17 |
- 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
- $1,935.76 / $2,016.42 / $2,581.02
| Professional | | $1,935.76 | $2,016.42 | $2,581.02 |