- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,715.35 / $6,309.57
| Facility | | $2,137.96 | $3,715.35 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,187.76 / $4,073.80
| Professional | | $2,137.96 | $2,187.76 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,884.03 / $5,888.44
| Facility | | $2,187.76 | $2,884.03 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,884.03
| Professional | | $2,137.96 | $2,137.96 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,137.96 / $3,162.28
| Facility | | $1,995.26 | $2,137.96 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,187.76 / $2,754.23
| Professional | | $2,137.96 | $2,187.76 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,137.96 / $3,715.35
| Facility | | $2,089.30 | $2,137.96 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,137.96 / $2,454.71
| Professional | | $2,089.30 | $2,137.96 | $2,454.71 |