- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,440.69 / $2,979.12 / $5,143.77
| Facility | | $2,440.69 | $2,979.12 | $5,143.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $2,953.25
| Professional | | $2,429.89 | $2,429.89 | $2,953.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,429.89 / $3,853.32 / $7,725.83
| Facility | | $2,429.89 | $3,853.32 | $7,725.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $2,521.58
| Professional | | $2,429.89 | $2,429.89 | $2,521.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,292.35 / $2,429.89 / $2,501.86
| Facility | | $2,292.35 | $2,429.89 | $2,501.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $2,636.20
| Professional | | $2,429.89 | $2,429.89 | $2,636.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,905.73 / $6,223.97 / $6,223.97
| Facility | | $5,905.73 | $6,223.97 | $6,223.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,503.21 / $2,891.57
| Professional | | $2,429.89 | $2,503.21 | $2,891.57 |