- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.32 / $5,438.94 / $6,098.06
| Facility | | $2,116.32 | $5,438.94 | $6,098.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $4,620.00 / $4,926.60
| Professional | | $2,116.32 | $4,620.00 | $4,926.60 |
- 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
- $2,086.62 / $2,088.42 / $6,023.33
| Facility | | $2,086.62 | $2,088.42 | $6,023.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.24 / $2,116.32 / $3,174.48
| Professional | | $1,941.24 | $2,116.32 | $3,174.48 |