- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,712.48 / $3,707.35 / $7,048.29
| Facility | | $2,712.48 | $3,707.35 | $7,048.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $3,078.11
| Professional | | $2,608.16 | $2,608.16 | $3,078.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,608.16 / $4,136.02 / $7,945.25
| Facility | | $2,608.16 | $4,136.02 | $7,945.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,608.16
| Professional | | $2,608.16 | $2,608.16 | $2,608.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,608.16
| Facility | | $2,608.16 | $2,608.16 | $2,608.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,608.16
| Professional | | $2,608.16 | $2,608.16 | $2,608.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,706.58 / $2,829.60 / $3,262.66
| Professional | | $2,706.58 | $2,829.60 | $3,262.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,483.96 / $2,608.16 / $2,868.98
| Professional | | $2,483.96 | $2,608.16 | $2,868.98 |