- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,429.89 / $7,614.98 / $9,274.66
| Facility | | $2,429.89 | $7,614.98 | $9,274.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $2,454.19
| Professional | | $2,429.89 | $2,429.89 | $2,454.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,440.69 / $2,440.69
| Professional | | $2,429.89 | $2,440.69 | $2,440.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,292.35 / $2,292.35 / $2,429.89
| Facility | | $2,292.35 | $2,292.35 | $2,429.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $3,094.67
| Professional | | $2,429.89 | $2,429.89 | $3,094.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.41 / $2,379.54 / $2,676.98
| Professional | | $2,065.41 | $2,379.54 | $2,676.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,704.98 / $3,576.85
| Professional | | $2,429.89 | $2,704.98 | $3,576.85 |