- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,113.23 / $2,366.83 / $4,226.47
| Facility | | $2,113.23 | $2,366.83 | $4,226.47 |
- 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
- $2,522.44 / $3,809.38 / $9,600.46
| Facility | | $2,522.44 | $3,809.38 | $9,600.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.23 / $2,116.32 / $2,116.32
| Professional | | $2,113.23 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,996.53 / $2,116.32 / $2,116.32
| Facility | | $1,996.53 | $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
- $2,080.03 / $3,219.56 / $6,118.96
| Professional | | $2,080.03 | $3,219.56 | $6,118.96 |
- 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
- $1,053.74 / $1,264.08 / $1,858.80
| Professional | | $1,053.74 | $1,264.08 | $1,858.80 |