- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,168.69 / $7,079.46
| Facility | | $2,454.71 | $4,168.69 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,090.30
| Professional | | $2,454.71 | $2,454.71 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,388.44 / $7,413.10
| Facility | | $2,570.40 | $3,388.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,311.31
| Professional | | $2,454.71 | $2,454.71 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,454.71 / $3,715.35
| Facility | | $2,290.87 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,951.21
| Professional | | $2,454.71 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,454.71 / $4,265.80
| Facility | | $1,995.26 | $2,454.71 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,818.38
| Professional | | $2,454.71 | $2,454.71 | $2,818.38 |