- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,885.20 / $2,591.34 / $2,720.91
| Facility | | $1,885.20 | $2,591.34 | $2,720.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,073.07 / $2,073.07 / $2,591.34
| Professional | | $2,073.07 | $2,073.07 | $2,591.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,203.14 / $3,671.07 / $7,913.68
| Facility | | $2,203.14 | $3,671.07 | $7,913.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,859.81 / $1,859.81 / $2,479.75
| Professional | | $1,859.81 | $1,859.81 | $2,479.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,202.64 / $2,202.64 / $2,202.64
| Facility | | $2,202.64 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,202.64 / $2,202.64 / $2,202.64
| Professional | | $2,202.64 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,994.84 / $2,203.14 / $11,383.05
| Facility | | $1,994.84 | $2,203.14 | $11,383.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.53 / $2,159.44 / $2,498.48
| Professional | | $1,835.53 | $2,159.44 | $2,498.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.53 / $2,159.44 / $2,692.83
| Professional | | $1,835.53 | $2,159.44 | $2,692.83 |