- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,673.16
| Facility | | $2,545.87 | $2,545.87 | $2,673.16 |
- 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
- $2,495.94 / $2,495.94 / $2,495.94
| Facility | | $2,495.94 | $2,495.94 | $2,495.94 |
- 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
- $360.04 / $2,545.87 / $2,545.87
| Facility | | $360.04 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Professional | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,475.48 / $2,495.94 / $2,870.34
| Professional | | $2,475.48 | $2,495.94 | $2,870.34 |