- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.07 / $1,857.07 / $3,714.14
| Facility | | $1,857.07 | $1,857.07 | $3,714.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.06 / $1,857.07 / $2,234.49
| Professional | | $1,857.06 | $1,857.07 | $2,234.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $745.07 / $1,884.38 / $3,158.39
| Facility | | $745.07 | $1,884.38 | $3,158.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,820.66 / $1,820.66 / $1,857.07
| Professional | | $1,820.66 | $1,820.66 | $1,857.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,039.14
| Facility | | $2,039.14 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,039.14
| Professional | | $2,039.14 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.28 / $2,123.77 / $2,250.34
| Professional | | $1,875.28 | $2,123.77 | $2,250.34 |