- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $3,332.46 / $4,740.35
| Facility | | $2,016.42 | $3,332.46 | $4,740.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,976.55 / $2,016.42 / $2,218.07
| Professional | | $1,976.55 | $2,016.42 | $2,218.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.29 / $2,016.42 / $2,028.40
| Facility | | $1,902.29 | $2,016.42 | $2,028.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Facility | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,130.56 / $2,130.56
| Professional | | $2,016.42 | $2,130.56 | $2,130.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Facility | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,235.91
| Professional | | $2,016.42 | $2,016.42 | $2,235.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,976.55 / $1,976.55 / $2,016.42
| Professional | | $1,976.55 | $1,976.55 | $2,016.42 |