- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.07 / $1,857.07 / $8,494.19
| Facility | | $1,857.07 | $1,857.07 | $8,494.19 |
- 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
- 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
- Facility
- Modifier
- Low / Median / High Price
- $2,075.55 / $9,193.40 / $9,193.40
| Facility | | $2,075.55 | $9,193.40 | $9,193.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.28 / $1,875.28 / $2,212.83
| Professional | | $1,875.28 | $1,875.28 | $2,212.83 |