- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $3,055.04
| Facility | | $2,545.87 | $2,545.87 | $3,055.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,066.65 / $2,545.87 / $2,545.87
| Professional | | $2,066.65 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.72 / $1,516.41 / $4,492.71
| Facility | | $511.72 | $1,516.41 | $4,492.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $2,545.86 / $2,545.86
| Professional | | $2,495.94 | $2,545.86 | $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
- $2,121.56 / $2,495.94 / $2,645.71
| Professional | | $2,121.56 | $2,495.94 | $2,645.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,800.46 / $3,564.22
| Professional | | $2,545.87 | $2,800.46 | $3,564.22 |