- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,365.16 / $7,413.10
| Facility | | $2,818.38 | $4,365.16 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $3,162.28
| Professional | | $2,511.89 | $2,511.89 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,981.07 / $6,606.93
| Facility | | $2,884.03 | $3,981.07 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,691.53
| Professional | | $2,511.89 | $2,511.89 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Professional | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,235.94
| Professional | | $2,754.23 | $2,754.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,511.89 / $2,818.38
| Professional | | $2,398.83 | $2,511.89 | $2,818.38 |