- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.07 / $1,857.07 / $3,772.04
| Facility | | $1,857.07 | $1,857.07 | $3,772.04 |
- 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
- $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
- $550.28 / $730.31 / $1,920.55
| Facility | | $550.28 | $730.31 | $1,920.55 |
- 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 |