- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,976.55 / $1,976.55 / $2,273.03
| Facility | | $1,976.55 | $1,976.55 | $2,273.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,976.55 / $2,036.58 / $2,520.53
| Professional | | $1,976.55 | $2,036.58 | $2,520.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.29 / $2,016.42 / $2,016.42
| Facility | | $1,902.29 | $2,016.42 | $2,016.42 |
- 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
- $2,218.07 / $2,671.76 / $3,604.36
| Facility | | $2,218.07 | $2,671.76 | $3,604.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,218.06 / $2,520.53
| Professional | | $2,016.42 | $2,218.06 | $2,520.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,059.64 / $2,942.34 / $4,904.56
| Facility | | $2,059.64 | $2,942.34 | $4,904.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,419.71 / $2,419.71 / $2,520.53
| Professional | | $2,419.71 | $2,419.71 | $2,520.53 |
- 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 |