- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,105.28 / $2,290.55 / $4,248.68
| Facility | | $2,105.28 | $2,290.55 | $4,248.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,285.63 / $2,285.63 / $2,351.23
| Professional | | $2,285.63 | $2,285.63 | $2,351.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $858.75 / $1,367.81 / $2,155.50
| Facility | | $858.75 | $1,367.81 | $2,155.50 |
- 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
- $1,053.02 / $2,116.32 / $2,116.32
| Professional | | $1,053.02 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,686.49 / $2,113.23 / $3,263.69
| Facility | | $1,686.49 | $2,113.23 | $3,263.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.71 / $2,113.23 / $2,116.32
| Professional | | $2,078.71 | $2,113.23 | $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 |