- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,150.81 / $2,202.64 / $4,690.32
| Facility | | $2,150.81 | $2,202.64 | $4,690.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,086.02 / $2,150.81 / $2,202.64
| Professional | | $2,086.02 | $2,150.81 | $2,202.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,203.14 / $3,586.71 / $6,888.65
| Facility | | $2,203.14 | $3,586.71 | $6,888.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,073.07 / $2,159.44 / $2,202.64
| Professional | | $2,073.07 | $2,159.44 | $2,202.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,202.64 / $2,202.64 / $2,202.64
| Facility | | $2,202.64 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,202.64 / $2,202.64 / $2,202.64
| Professional | | $2,202.64 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.44 / $2,159.44 / $2,828.88
| Professional | | $2,159.44 | $2,159.44 | $2,828.88 |