- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,073.07 / $2,073.07 / $3,964.75
| Facility | | $2,073.07 | $2,073.07 | $3,964.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,073.07 / $2,591.34 / $2,591.34
| Professional | | $2,073.07 | $2,591.34 | $2,591.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,267.42 / $2,278.76 / $2,308.01
| Facility | | $2,267.42 | $2,278.76 | $2,308.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,927.31 / $2,275.36 / $2,308.01
| Professional | | $1,927.31 | $2,275.36 | $2,308.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.63 / $635.91 / $799.62
| Professional | | $629.63 | $635.91 | $799.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $844.73 / $2,073.07 / $6,219.21
| Facility | | $844.73 | $2,073.07 | $6,219.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.44 / $2,159.44 / $2,345.27
| Professional | | $2,159.44 | $2,159.44 | $2,345.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.53 / $2,159.44 / $2,345.27
| Professional | | $1,835.53 | $2,159.44 | $2,345.27 |