- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,925.47 / $3,129.79 / $3,205.30
| Facility | | $2,925.47 | $3,129.79 | $3,205.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,738.56 / $3,129.79
| Professional | | $2,608.16 | $2,738.56 | $3,129.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,759.89 / $2,759.89 / $2,759.89
| Facility | | $2,759.89 | $2,759.89 | $2,759.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,759.89 / $2,759.89 / $2,774.32
| Professional | | $2,759.89 | $2,759.89 | $2,774.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,078.48 / $2,608.16 / $2,608.16
| Facility | | $2,078.48 | $2,608.16 | $2,608.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,829.60
| Professional | | $2,608.16 | $2,608.16 | $2,829.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $3,338.44
| Professional | | $2,608.16 | $2,608.16 | $3,338.44 |