- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,995.14 / $5,026.06
| Facility | | $2,545.87 | $2,995.14 | $5,026.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,485.96 / $2,545.87
| Professional | | $2,396.11 | $2,485.96 | $2,545.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $359.09 / $953.11 / $3,060.14
| Facility | | $359.09 | $953.11 | $3,060.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.09 / $2,321.23 / $2,545.86
| Professional | | $529.09 | $2,321.23 | $2,545.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Facility | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Professional | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,645.71 / $2,645.71 / $2,645.71
| Facility | | $2,645.71 | $2,645.71 | $2,645.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $2,495.94 / $2,970.18
| Professional | | $2,495.94 | $2,495.94 | $2,970.18 |