- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,035.85 / $2,076.92 / $6,351.85
| Facility | | $2,035.85 | $2,076.92 | $6,351.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,076.92 / $2,391.63
| Professional | | $2,016.42 | $2,076.92 | $2,391.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,406.39 / $4,490.43 / $8,494.58
| Facility | | $2,406.39 | $4,490.43 | $8,494.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,497.53 / $1,761.81 / $2,054.46
| Professional | | $1,497.53 | $1,761.81 | $2,054.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.50 / $2,016.42 / $2,016.42
| Professional | | $1,736.50 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,544.81 / $5,664.75
| Facility | | $2,016.42 | $2,544.81 | $5,664.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,035.85 / $2,419.69
| Professional | | $2,016.42 | $2,035.85 | $2,419.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,214.01 / $2,273.03 / $2,318.88
| Professional | | $2,214.01 | $2,273.03 | $2,318.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,139.42
| Professional | | $2,016.42 | $2,016.42 | $2,139.42 |