- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,488.32 / $3,110.40 / $5,923.20
| Facility | | $2,488.32 | $3,110.40 | $5,923.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,517.36 / $2,643.84 / $2,839.79
| Professional | | $2,517.36 | $2,643.84 | $2,839.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,436.60 / $2,928.72 / $5,601.38
| Facility | | $1,436.60 | $2,928.72 | $5,601.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,488.32 / $2,592.00 / $2,753.61
| Professional | | $2,488.32 | $2,592.00 | $2,753.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,643.84 / $2,643.84 / $2,643.84
| Facility | | $2,643.84 | $2,643.84 | $2,643.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,643.84 / $2,643.84 / $2,643.84
| Professional | | $2,643.84 | $2,643.84 | $2,643.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $3,110.40
| Professional | | $2,592.00 | $2,592.00 | $3,110.40 |