- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,008.95 / $3,356.97 / $6,638.82
| Facility | | $3,008.95 | $3,356.97 | $6,638.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,935.58 / $3,008.95 / $3,081.45
| Professional | | $2,935.58 | $3,008.95 | $3,081.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,301.91 / $4,186.87 / $8,269.95
| Facility | | $2,301.91 | $4,186.87 | $8,269.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,718.93 / $3,021.04 / $3,111.67
| Professional | | $2,718.93 | $3,021.04 | $3,111.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Facility | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.04 / $3,021.04 / $3,323.14
| Professional | | $3,021.04 | $3,021.04 | $3,323.14 |