- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,698.05 / $3,507.46 / $5,879.05
| Facility | | $2,698.05 | $3,507.46 | $5,879.05 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $2,658.13 / $2,825.32 / $3,232.57
| Professional | | $2,658.13 | $2,825.32 | $3,232.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,658.13 / $2,698.05 / $2,698.05
| Facility | | $2,658.13 | $2,698.05 | $2,698.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,698.05
| Professional | | $2,698.05 | $2,698.05 | $2,698.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,535.81 / $3,633.50 / $13,490.25
| Facility | | $3,535.81 | $3,633.50 | $13,490.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,735.90 / $11,735.90 / $11,735.90
| Professional | | $11,735.90 | $11,735.90 | $11,735.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,563.15 / $2,698.05 / $3,021.82
| Professional | | $2,563.15 | $2,698.05 | $3,021.82 |