- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,976.55 / $2,134.67 / $3,628.96
| Facility | | $1,976.55 | $2,134.67 | $3,628.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,177.73 / $2,177.73 / $2,240.23
| Professional | | $2,177.73 | $2,177.73 | $2,240.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $874.69 / $1,367.81 / $2,128.50
| Facility | | $874.69 | $1,367.81 | $2,128.50 |
- 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
- $1,673.36 / $2,134.67 / $3,052.59
| Facility | | $1,673.36 | $2,134.67 | $3,052.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.23 / $1,976.55 / $1,976.55
| Professional | | $1,925.23 | $1,976.55 | $1,976.55 |
- 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 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |