- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,202.64 / $3,308.14 / $7,241.50
| Facility | | $2,202.64 | $3,308.14 | $7,241.50 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $2,014.36 / $3,282.80 / $6,472.95
| Facility | | $2,014.36 | $3,282.80 | $6,472.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.44 / $2,159.44 / $2,202.63
| Professional | | $2,159.44 | $2,159.44 | $2,202.63 |
- 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
- $2,202.64 / $2,202.64 / $2,202.64
| Professional | | $2,202.64 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.51 / $2,159.44 / $3,108.49
| Professional | | $1,943.51 | $2,159.44 | $3,108.49 |