- 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 / $2,725.03 / $3,705.23
| Professional | | $2,698.05 | $2,725.03 | $3,705.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,710.47 / $3,188.79 / $3,188.79
| Professional | | $2,710.47 | $3,188.79 | $3,188.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.33 / $2,545.33 / $2,545.33
| Facility | | $2,545.33 | $2,545.33 | $2,545.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $3,308.93 / $3,818.00
| Professional | | $2,698.05 | $3,308.93 | $3,818.00 |
- 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 |