- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,351.23 / $3,630.55
| Professional | | $2,116.32 | $2,351.23 | $3,630.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,395.84 / $2,395.84 / $2,395.84
| Facility | | $2,395.84 | $2,395.84 | $2,395.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,996.53 / $2,353.26 / $3,922.10
| Facility | | $1,996.53 | $2,353.26 | $3,922.10 |
- 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
- $1,996.53 / $2,353.26 / $3,922.10
| Facility | | $1,996.53 | $2,353.26 | $3,922.10 |
- 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
- $2,062.57 / $2,116.32 / $3,255.56
| Professional | | $2,062.57 | $2,116.32 | $3,255.56 |