- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $3,803.83
| Facility | | $2,116.32 | $2,116.32 | $3,803.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,137.48 / $2,557.02
| Professional | | $2,116.32 | $2,137.48 | $2,557.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,296.01 / $2,307.48 / $2,337.11
| Facility | | $2,296.01 | $2,307.48 | $2,337.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,951.61 / $2,304.05 / $2,324.71
| Professional | | $1,951.61 | $2,304.05 | $2,324.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.92 / $2,117.92 / $2,647.41
| Professional | | $2,117.92 | $2,117.92 | $2,647.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,001.49 / $2,098.00 / $3,592.51
| Facility | | $2,001.49 | $2,098.00 | $3,592.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.71 / $2,113.23 / $2,295.08
| Professional | | $2,078.71 | $2,113.23 | $2,295.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.87 / $2,116.32 / $2,298.42
| Professional | | $1,798.87 | $2,116.32 | $2,298.42 |