- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,030.50 / $2,226.61 / $2,350.35
| Facility | | $2,030.50 | $2,226.61 | $2,350.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,742.73 / $2,226.61 / $2,863.71
| Professional | | $1,742.73 | $2,226.61 | $2,863.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.98 / $1,751.98 / $3,381.32
| Facility | | $1,751.98 | $1,751.98 | $3,381.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.98 / $1,949.51 / $3,496.60
| Professional | | $1,751.98 | $1,949.51 | $3,496.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,685.49 / $3,685.49 / $3,685.49
| Facility | | $3,685.49 | $3,685.49 | $3,685.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.45 / $3,661.49 / $3,685.49
| Professional | | $218.45 | $3,661.49 | $3,685.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.44 / $313.07 / $2,127.11
| Professional | | $154.44 | $313.07 | $2,127.11 |