- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,677.35 / $8,128.31
| Facility | | $2,818.38 | $4,677.35 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,715.35
| Professional | | $2,818.38 | $2,818.38 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,890.45 / $7,762.47
| Facility | | $2,951.21 | $3,890.45 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,801.89
| Professional | | $2,818.38 | $2,818.38 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,818.38 / $3,981.07
| Facility | | $2,630.27 | $2,818.38 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,162.28
| Professional | | $2,818.38 | $2,818.38 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,818.38 / $4,786.30
| Facility | | $2,630.27 | $2,818.38 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,818.38 / $3,162.28
| Professional | | $2,691.53 | $2,818.38 | $3,162.28 |