- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,896.00 / $2,117.23 / $8,390.76
| Facility | | $1,896.00 | $2,117.23 | $8,390.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,793.85 / $2,016.42 / $2,117.23
| Professional | | $1,793.85 | $2,016.42 | $2,117.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,333.43 / $2,275.73 / $3,593.66
| Facility | | $1,333.43 | $2,275.73 | $3,593.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,540.81 / $2,782.67
| Professional | | $2,016.42 | $2,540.81 | $2,782.67 |
- 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
- $2,117.23 / $2,540.69 / $4,935.37
| Facility | | $2,117.23 | $2,540.69 | $4,935.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,127.30 / $3,127.30 / $3,127.30
| Professional | | $3,127.30 | $3,127.30 | $3,127.30 |
- 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 |