- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,698.05 / $6,529.28 / $10,252.60
| Facility | | $2,698.05 | $6,529.28 | $10,252.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,967.86
| Professional | | $2,698.05 | $2,698.05 | $2,967.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,710.47
| Professional | | $2,698.05 | $2,698.05 | $2,710.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.33 / $2,545.33 / $2,698.05
| Facility | | $2,545.33 | $2,545.33 | $2,698.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $3,436.20
| Professional | | $2,698.05 | $2,698.05 | $3,436.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.34 / $2,550.78 / $2,869.62
| Professional | | $2,293.34 | $2,550.78 | $2,869.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $3,003.50 / $3,971.58
| Professional | | $2,698.05 | $3,003.50 | $3,971.58 |