- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,073.07 / $2,150.81 / $5,675.04
| Facility | | $2,073.07 | $2,150.81 | $5,675.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,073.07 / $2,150.81 / $2,202.64
| Professional | | $2,073.07 | $2,150.81 | $2,202.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,202.64 / $2,202.64 / $2,313.30
| Facility | | $2,202.64 | $2,202.64 | $2,313.30 |
- 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
- $2,202.64 / $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 / $2,929.14
| Professional | | $2,159.44 | $2,159.44 | $2,929.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,066.46 / $2,066.46 / $2,066.46
| Professional | | $2,066.46 | $2,066.46 | $2,066.46 |