- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.27 / $1,980.30 / $2,228.48
| Facility | | $1,800.27 | $1,980.30 | $2,228.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.07 / $1,857.07 / $2,284.19
| Professional | | $1,857.07 | $1,857.07 | $2,284.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,773.50 / $2,034.31 / $2,086.46
| Facility | | $1,773.50 | $2,034.31 | $2,086.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,753.34 / $1,753.34 / $1,753.34
| Professional | | $1,753.34 | $1,753.34 | $1,753.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,039.14
| Facility | | $2,039.14 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,039.14
| Professional | | $2,039.14 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $719.87 / $1,800.27 / $2,284.19
| Facility | | $719.87 | $1,800.27 | $2,284.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,002.80 / $2,123.77 / $2,250.34
| Professional | | $2,002.80 | $2,123.77 | $2,250.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,002.80 / $2,123.77 / $2,390.73
| Professional | | $2,002.80 | $2,123.77 | $2,390.73 |