- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.32 / $4,190.56 / $6,603.87
| Facility | | $2,116.32 | $4,190.56 | $6,603.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,351.23 / $3,254.23
| Professional | | $2,116.32 | $2,351.23 | $3,254.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,327.94 / $3,715.83 / $6,772.22
| Facility | | $2,327.94 | $3,715.83 | $6,772.22 |
- 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 / $1,996.53 / $2,994.80
| Facility | | $1,996.53 | $1,996.53 | $2,994.80 |
- 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
- $1,126.10 / $2,243.30 / $3,510.55
| Facility | | $1,126.10 | $2,243.30 | $3,510.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,587.24 / $2,327.96 / $3,470.76
| Professional | | $1,587.24 | $2,327.96 | $3,470.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,236.13 / $6,236.13 / $6,236.13
| Facility | | $6,236.13 | $6,236.13 | $6,236.13 |
- 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 |