- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,426.06 / $2,426.06 / $3,420.50
| Facility | | $2,426.06 | $2,426.06 | $3,420.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,456.01 / $2,545.87
| Professional | | $2,396.11 | $2,456.01 | $2,545.87 |
- 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
- $2,396.11 / $2,547.36 / $2,995.14
| Facility | | $2,396.11 | $2,547.36 | $2,995.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $2,645.71 / $11,381.53
| Professional | | $2,495.94 | $2,645.71 | $11,381.53 |
- 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 |