- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,150.81 / $2,796.05 / $4,258.60
| Facility | | $2,150.81 | $2,796.05 | $4,258.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,073.07 / $2,150.81 / $2,150.81
| Professional | | $2,073.07 | $2,150.81 | $2,150.81 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $2,461.77 / $11,383.05 / $11,383.05
| Facility | | $2,461.77 | $11,383.05 | $11,383.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.44 / $2,159.44 / $2,871.97
| Professional | | $2,159.44 | $2,159.44 | $2,871.97 |