- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,113.23 / $2,218.90 / $5,252.75
| Facility | | $2,113.23 | $2,218.90 | $5,252.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,137.48 / $2,557.02
| Professional | | $2,116.32 | $2,137.48 | $2,557.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $779.96 / $879.96 / $2,966.46
| Facility | | $779.96 | $879.96 | $2,966.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,977.64 / $1,977.64 / $2,017.19
| Professional | | $1,977.64 | $1,977.64 | $2,017.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $2,137.46 / $2,137.46
| Facility | | $40.00 | $2,137.46 | $2,137.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,996.53 / $1,996.53 / $2,116.32
| Facility | | $1,996.53 | $1,996.53 | $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
- $2,073.98 / $2,116.32 / $2,426.55
| Professional | | $2,073.98 | $2,116.32 | $2,426.55 |