- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,113.23 / $2,979.78 / $6,369.69
| Facility | | $2,113.23 | $2,979.78 | $6,369.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,351.23 / $2,979.78
| Professional | | $2,116.32 | $2,351.23 | $2,979.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,996.53 / $2,116.32 / $2,116.32
| Facility | | $1,996.53 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,116.32
| Professional | | $2,116.32 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $608.54 / $2,645.40 / $3,782.92
| Facility | | $608.54 | $2,645.40 | $3,782.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,645.40
| Professional | | $2,116.32 | $2,116.32 | $2,645.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,065.84 / $3,098.76 / $5,203.87
| Facility | | $2,065.84 | $3,098.76 | $5,203.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,539.59 / $2,539.59 / $2,645.40
| Professional | | $2,539.59 | $2,539.59 | $2,645.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,182.21
| Professional | | $2,116.32 | $2,116.32 | $2,182.21 |