- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $4,093.76 / $8,369.92
| Facility | | $2,545.87 | $4,093.76 | $8,369.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,545.87 / $2,545.87
| Professional | | $2,396.11 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $359.09 / $3,958.08 / $8,627.00
| Facility | | $359.09 | $3,958.08 | $8,627.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,495.94 / $2,545.86
| Professional | | $2,396.11 | $2,495.94 | $2,545.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Facility | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Professional | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Professional | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.15 / $2,495.94 / $2,755.53
| Professional | | $2,371.15 | $2,495.94 | $2,755.53 |