- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,832.95 / $2,913.90 / $4,108.31
| Facility | | $2,832.95 | $2,913.90 | $4,108.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,752.01 / $3,264.64
| Professional | | $2,698.05 | $2,752.01 | $3,264.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $858.75 / $1,354.69 / $2,148.00
| Facility | | $858.75 | $1,354.69 | $2,148.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.33 / $2,545.33 / $2,698.05
| Facility | | $2,545.33 | $2,545.33 | $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
- Facility
- Modifier
- Low / Median / High Price
- $2,270.31 / $2,913.90 / $4,166.88
| Facility | | $2,270.31 | $2,913.90 | $4,166.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,563.15 / $2,698.05 / $3,394.15
| Professional | | $2,563.15 | $2,698.05 | $3,394.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $3,021.82
| Professional | | $2,698.05 | $2,698.05 | $3,021.82 |