- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,097.08 / $3,160.74 / $5,634.89
| Facility | | $2,097.08 | $3,160.74 | $5,634.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,097.08 / $2,097.08 / $2,097.08
| Professional | | $2,097.08 | $2,097.08 | $2,097.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,076.31 / $3,065.36 / $6,044.22
| Facility | | $2,076.31 | $3,065.36 | $6,044.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Facility | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.52 / $2,410.77 / $2,540.81
| Professional | | $2,092.52 | $2,410.77 | $2,540.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.78 / $2,016.42 / $2,337.55
| Professional | | $1,814.78 | $2,016.42 | $2,337.55 |