- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,653.44 / $2,116.32 / $4,490.63
| Facility | | $1,653.44 | $2,116.32 | $4,490.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,557.02
| Professional | | $2,116.32 | $2,116.32 | $2,557.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,372.69 / $2,372.69 / $2,372.69
| Professional | | $2,372.69 | $2,372.69 | $2,372.69 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $2,765.08 / $10,393.54 / $10,581.60
| Facility | | $2,765.08 | $10,393.54 | $10,581.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.57 / $2,116.32 / $2,116.32
| Professional | | $2,062.57 | $2,116.32 | $2,116.32 |