- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,736.91
| Facility | | $2,326.37 | $2,326.37 | $2,736.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Professional | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.88 / $88.68 / $133.02
| Facility | | $85.88 | $88.68 | $133.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,554.44 / $2,554.44
| Facility | | $2,326.37 | $2,554.44 | $2,554.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.44 / $2,554.44 / $3,326.23
| Professional | | $2,554.44 | $2,554.44 | $3,326.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.17 / $2,736.91 / $3,758.69
| Professional | | $2,349.17 | $2,736.91 | $3,758.69 |