- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.07 / $1,857.07 / $1,857.07
| Facility | | $1,857.07 | $1,857.07 | $1,857.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.07 / $1,857.07 / $1,857.07
| Professional | | $1,857.07 | $1,857.07 | $1,857.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,774.09 / $1,774.09 / $1,774.09
| Professional | | $1,774.09 | $1,774.09 | $1,774.09 |
- 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
- $1,856.53 / $2,119.07 / $2,548.52
| Professional | | $1,856.53 | $2,119.07 | $2,548.52 |