- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,035.85 / $2,569.26 / $3,455.50
| Facility | | $2,035.85 | $2,569.26 | $3,455.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,076.92 / $2,419.71
| Professional | | $2,016.42 | $2,076.92 | $2,419.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $3,427.91 / $7,242.98
| Facility | | $2,016.42 | $3,427.91 | $7,242.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,520.53
| Professional | | $2,016.42 | $2,016.42 | $2,520.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.29 / $1,902.29 / $2,016.42
| Facility | | $1,902.29 | $1,902.29 | $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
- $1,976.55 / $2,419.69 / $9,626.15
| Facility | | $1,976.55 | $2,419.69 | $9,626.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.07 / $1,976.55 / $2,273.03
| Professional | | $1,680.07 | $1,976.55 | $2,273.03 |
- 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
- $1,713.96 / $2,016.42 / $2,333.00
| Professional | | $1,713.96 | $2,016.42 | $2,333.00 |