- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,608.16 / $7,936.94 / $9,666.78
| Facility | | $2,608.16 | $7,936.94 | $9,666.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,634.24
| Professional | | $2,608.16 | $2,608.16 | $2,634.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,543.89 / $2,543.89 / $3,047.87
| Professional | | $2,543.89 | $2,543.89 | $3,047.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,460.53 / $2,460.53 / $2,608.16
| Facility | | $2,460.53 | $2,460.53 | $2,608.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $3,321.71
| Professional | | $2,608.16 | $2,608.16 | $3,321.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,216.94 / $2,608.16 / $3,187.39
| Professional | | $2,216.94 | $2,608.16 | $3,187.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,903.43 / $3,839.26
| Professional | | $2,608.16 | $2,903.43 | $3,839.26 |