- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,157.94 / $3,079.74 / $5,719.14
| Facility | | $2,157.94 | $3,079.74 | $5,719.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,200.98 / $2,200.98 / $2,200.98
| Professional | | $2,200.98 | $2,200.98 | $2,200.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.32 / $3,217.23 / $6,539.85
| Facility | | $2,116.32 | $3,217.23 | $6,539.85 |
- 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
- $2,116.32 / $2,116.32 / $2,116.32
| Facility | | $2,116.32 | $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
- Professional
- Modifier
- Low / Median / High Price
- $2,196.17 / $2,196.17 / $2,647.40
| Professional | | $2,196.17 | $2,196.17 | $2,647.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,904.69 / $2,116.32 / $2,232.42
| Professional | | $1,904.69 | $2,116.32 | $2,232.42 |