- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.32 / $3,931.31 / $5,344.56
| Facility | | $2,116.32 | $3,931.31 | $5,344.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,351.23
| Professional | | $2,116.32 | $2,116.32 | $2,351.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,996.53 / $2,116.32 / $2,171.31
| Facility | | $1,996.53 | $2,116.32 | $2,171.31 |
- 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
- $804.87 / $2,116.32 / $2,116.32
| Facility | | $804.87 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,156.25 / $2,156.25
| Professional | | $2,116.32 | $2,156.25 | $2,156.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,426.55
| Professional | | $2,116.32 | $2,116.32 | $2,426.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.23 / $2,113.23 / $2,116.32
| Professional | | $2,113.23 | $2,113.23 | $2,116.32 |