- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,698.05 / $3,305.11 / $5,907.38
| Facility | | $2,698.05 | $3,305.11 | $5,907.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $3,264.64
| Professional | | $2,698.05 | $2,698.05 | $3,264.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,698.05 / $4,313.24 / $8,578.45
| Facility | | $2,698.05 | $4,313.24 | $8,578.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,849.41
| Professional | | $2,698.05 | $2,698.05 | $2,849.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.33 / $2,698.05 / $2,698.05
| Facility | | $2,545.33 | $2,698.05 | $2,698.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,799.87
| Professional | | $2,698.05 | $2,698.05 | $2,799.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $3,188.47
| Professional | | $2,698.05 | $2,698.05 | $3,188.47 |