- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $6,025.60 / $7,244.36
| Facility | | $3,019.95 | $6,025.60 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $3,630.78
| Professional | | $2,884.03 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,162.28 / $9,549.93
| Facility | | $2,754.23 | $3,162.28 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,511.89 / $3,090.30
| Professional | | $2,290.87 | $2,511.89 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,090.30 / $3,090.30
| Facility | | $2,754.23 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Professional | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,019.95 / $3,467.37
| Professional | | $2,951.21 | $3,019.95 | $3,467.37 |