- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Facility | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,485.96 / $2,545.87
| Professional | | $2,396.11 | $2,485.96 | $2,545.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,921.89 / $2,332.31 / $3,137.71
| Facility | | $1,921.89 | $2,332.31 | $3,137.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $2,495.94 / $2,495.94
| Professional | | $2,495.94 | $2,495.94 | $2,495.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Facility | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.21 / $2,545.87 / $2,545.87
| Professional | | $1,270.21 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,121.56 / $2,495.94 / $2,893.06
| Professional | | $2,121.56 | $2,495.94 | $2,893.06 |