- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,460.87 / $2,543.89 / $2,543.89
| Facility | | $2,460.87 | $2,543.89 | $2,543.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $3,790.40
| Professional | | $2,608.16 | $2,608.16 | $3,790.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,543.89 / $2,543.89 / $2,608.16
| Professional | | $2,543.89 | $2,543.89 | $2,608.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,732.53 / $2,732.53 / $3,010.31
| Facility | | $2,732.53 | $2,732.53 | $3,010.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $3,075.66
| Professional | | $2,608.16 | $2,608.16 | $3,075.66 |
- 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 / $3,135.70
| Professional | | $2,608.16 | $2,903.43 | $3,135.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.53 / $2,732.53 / $3,434.25
| Professional | | $2,732.53 | $2,732.53 | $3,434.25 |