- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,805.98 / $3,932.02 / $7,291.21
| Facility | | $2,805.98 | $3,932.02 | $7,291.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,725.03 / $3,264.64
| Professional | | $2,698.05 | $2,725.03 | $3,264.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,698.05 / $4,101.58 / $8,087.40
| Facility | | $2,698.05 | $4,101.58 | $8,087.40 |
- 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 / $2,698.05 / $2,698.05
| Facility | | $2,698.05 | $2,698.05 | $2,698.05 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $2,575.98 / $2,799.86 / $3,225.70
| Professional | | $2,575.98 | $2,799.86 | $3,225.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,508.65 / $2,698.05 / $2,967.86
| Professional | | $2,508.65 | $2,698.05 | $2,967.86 |