- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,273.03 / $2,419.71 / $2,422.09
| Facility | | $2,273.03 | $2,419.71 | $2,422.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,240.23 / $2,419.71
| Professional | | $2,016.42 | $2,240.23 | $2,419.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,144.37 / $2,144.37 / $2,144.37
| Facility | | $2,144.37 | $2,144.37 | $2,144.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.88 / $2,144.37 / $2,144.37
| Professional | | $1,997.88 | $2,144.37 | $2,144.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,802.08 / $2,016.42 / $2,016.42
| Facility | | $1,802.08 | $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
- 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 |