- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,976.55 / $1,976.55 / $3,953.10
| Facility | | $1,976.55 | $1,976.55 | $3,953.10 |
- 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
- $2,403.37 / $3,629.56 / $9,147.29
| Facility | | $2,403.37 | $3,629.56 | $9,147.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,976.55 / $2,016.42 / $2,016.42
| Professional | | $1,976.55 | $2,016.42 | $2,016.42 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $2,115.63 / $3,274.67 / $6,223.68
| Professional | | $2,115.63 | $3,274.67 | $6,223.68 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $1,865.63 / $2,275.19 / $3,290.97
| Professional | | $1,865.63 | $2,275.19 | $3,290.97 |