- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,995.14 / $3,144.90 / $8,356.44
| Facility | | $2,995.14 | $3,144.90 | $8,356.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,426.06 / $2,995.14 / $2,995.14
| Professional | | $2,426.06 | $2,995.14 | $2,995.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,695.63 / $2,695.63 / $4,043.45
| Facility | | $2,695.63 | $2,695.63 | $4,043.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,560.85 / $2,695.63 / $2,749.54
| Professional | | $2,560.85 | $2,695.63 | $2,749.54 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $2,246.36 / $2,495.94 / $2,872.84
| Professional | | $2,246.36 | $2,495.94 | $2,872.84 |