- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,512.48 / $2,512.48 / $2,512.48
| Facility | | $2,512.48 | $2,512.48 | $2,512.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,512.48 / $2,512.48 / $2,512.48
| Professional | | $2,512.48 | $2,512.48 | $2,512.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,554.44 / $2,554.44 / $2,554.44
| Facility | | $2,554.44 | $2,554.44 | $2,554.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.44 / $2,554.44 / $2,554.44
| Professional | | $2,554.44 | $2,554.44 | $2,554.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,722.80 / $2,512.48 / $3,592.85
| Facility | | $1,722.80 | $2,512.48 | $3,592.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.71 / $2,736.91 / $2,819.02
| Professional | | $2,231.71 | $2,736.91 | $2,819.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.71 / $2,703.91 / $2,819.02
| Professional | | $2,231.71 | $2,703.91 | $2,819.02 |