- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.32 / $3,258.70 / $5,344.56
| Facility | | $2,116.32 | $3,258.70 | $5,344.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,201.81 / $2,957.60
| Professional | | $2,116.32 | $2,201.81 | $2,957.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.32 / $3,521.55 / $6,728.84
| Facility | | $2,116.32 | $3,521.55 | $6,728.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,116.32
| Professional | | $2,116.32 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,996.53 / $2,116.32 / $2,116.32
| Facility | | $1,996.53 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,116.32
| Professional | | $2,116.32 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,152.39 / $5,430.04 / $5,430.04
| Facility | | $5,152.39 | $5,430.04 | $5,430.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,327.94
| Professional | | $2,116.32 | $2,116.32 | $2,327.94 |