- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,859.94 / $5,396.10 / $5,638.92
| Facility | | $2,859.94 | $5,396.10 | $5,638.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $3,264.64
| Professional | | $2,698.05 | $2,698.05 | $3,264.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,967.86 / $4,737.24 / $8,633.76
| Facility | | $2,967.86 | $4,737.24 | $8,633.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,698.05
| Professional | | $2,698.05 | $2,698.05 | $2,698.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.33 / $2,545.33 / $3,818.00
| Facility | | $2,545.33 | $2,545.33 | $3,818.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,698.05
| Professional | | $2,698.05 | $2,698.05 | $2,698.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,859.94 / $4,547.30
| Facility | | $2,698.05 | $2,859.94 | $4,547.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,940.88 / $2,967.86 / $4,047.08
| Professional | | $2,940.88 | $2,967.86 | $4,047.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,859.93
| Professional | | $2,698.05 | $2,698.05 | $2,859.93 |