- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.21 / $2,547.88 / $4,952.20
| Facility | | $1,263.21 | $2,547.88 | $4,952.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,134.37 / $2,426.55 / $3,935.19
| Professional | | $2,134.37 | $2,426.55 | $3,935.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.32 / $3,597.74 / $7,601.82
| Facility | | $2,116.32 | $3,597.74 | $7,601.82 |
- 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
- $1,996.53 / $1,996.53 / $2,116.32
| Facility | | $1,996.53 | $1,996.53 | $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
- $2,049.21 / $2,539.58 / $10,393.54
| Facility | | $2,049.21 | $2,539.58 | $10,393.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.25 / $2,113.23 / $2,378.02
| Professional | | $1,796.25 | $2,113.23 | $2,378.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.87 / $2,116.32 / $2,378.02
| Professional | | $1,798.87 | $2,116.32 | $2,378.02 |