- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,976.55 / $3,221.78 / $4,200.17
| Facility | | $1,976.55 | $3,221.78 | $4,200.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,240.23
| Professional | | $2,016.42 | $2,016.42 | $2,240.23 |
- 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 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,560.91 / $9,626.15 / $10,082.10
| Facility | | $2,560.91 | $9,626.15 | $10,082.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,925.23 / $2,016.42 / $2,016.42
| Facility | | $1,925.23 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,159.69
| Professional | | $2,016.42 | $2,016.42 | $2,159.69 |