- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,240.23 / $3,395.71
| Professional | | $2,016.42 | $2,240.23 | $3,395.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.29 / $2,179.51 / $3,632.51
| Facility | | $1,902.29 | $2,179.51 | $3,632.51 |
- 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
- $1,902.29 / $2,179.51 / $3,632.51
| Facility | | $1,902.29 | $2,179.51 | $3,632.51 |
- 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
- $1,915.60 / $2,016.42 / $2,159.69
| Professional | | $1,915.60 | $2,016.42 | $2,159.69 |