- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,976.55 / $1,976.55 / $2,036.59
| Facility | | $1,976.55 | $1,976.55 | $2,036.59 |
- 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 / $3,024.63 / $3,024.63
| Facility | | $2,016.42 | $3,024.63 | $3,024.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.29 / $2,016.42 / $2,159.69
| Facility | | $1,902.29 | $2,016.42 | $2,159.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $3,701.06
| Professional | | $2,016.42 | $2,016.42 | $3,701.06 |
- 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 |