- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,098.00 / $4,893.21 / $8,363.73
| Facility | | $2,098.00 | $4,893.21 | $8,363.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,137.48 / $2,351.23
| Professional | | $2,116.32 | $2,137.48 | $2,351.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.32 / $3,174.48 / $3,174.48
| Facility | | $2,116.32 | $3,174.48 | $3,174.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,996.53 / $2,078.71 / $2,116.32
| Facility | | $1,996.53 | $2,078.71 | $2,116.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $3,897.82
| Professional | | $2,116.32 | $2,116.32 | $3,897.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.32 / $3,959.68 / $6,695.01
| Facility | | $2,116.32 | $3,959.68 | $6,695.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.57 / $2,116.32 / $2,426.55
| Professional | | $2,062.57 | $2,116.32 | $2,426.55 |