- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $4,856.49
| Facility | | $2,698.05 | $2,698.05 | $4,856.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $3,705.23
| Professional | | $2,698.05 | $2,698.05 | $3,705.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,927.13 / $2,941.77 / $2,979.53
| Facility | | $2,927.13 | $2,941.77 | $2,979.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,496.77 / $2,941.77 / $2,979.53
| Professional | | $2,496.77 | $2,941.77 | $2,979.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,708.29 / $3,439.53
| Professional | | $2,698.05 | $2,708.29 | $3,439.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,529.55 / $2,805.98 / $4,856.49
| Facility | | $2,529.55 | $2,805.98 | $4,856.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $3,003.50 / $11,735.90
| Professional | | $2,698.05 | $3,003.50 | $11,735.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $3,261.95
| Professional | | $2,698.05 | $2,698.05 | $3,261.95 |