- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,698.05
| Facility | | $2,698.05 | $2,698.05 | $2,698.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $3,270.04
| Professional | | $2,698.05 | $2,698.05 | $3,270.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,477.62 / $2,883.81 / $5,707.57
| Facility | | $2,477.62 | $2,883.81 | $5,707.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,266.37 / $2,747.97 / $2,832.96
| Professional | | $2,266.37 | $2,747.97 | $2,832.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,391.00 / $4,148.35 / $8,567.56
| Facility | | $3,391.00 | $4,148.35 | $8,567.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,708.29 / $2,979.12 / $3,439.53
| Professional | | $2,708.29 | $2,979.12 | $3,439.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,199.06 / $4,089.98 / $9,324.02
| Facility | | $3,199.06 | $4,089.98 | $9,324.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,708.29 / $2,708.29 / $2,846.16
| Professional | | $2,708.29 | $2,708.29 | $2,846.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $5,945.76
| Facility | | $2,698.05 | $2,698.05 | $5,945.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $3,003.50 / $6,938.58
| Professional | | $2,698.05 | $3,003.50 | $6,938.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,859.93 / $5,161.67
| Professional | | $2,698.05 | $2,859.93 | $5,161.67 |