- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,588.07 / $2,147.08 / $2,147.08
| Facility | | $1,588.07 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.56 / $2,147.08 / $2,147.08
| Professional | | $2,096.56 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,399.67 / $2,399.67 / $2,399.67
| Facility | | $2,399.67 | $2,399.67 | $2,399.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,399.67 / $2,399.67 / $2,399.67
| Professional | | $2,399.67 | $2,399.67 | $2,399.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,823.89 / $2,147.08 / $2,147.08
| Facility | | $1,823.89 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Professional | | $2,147.08 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.98 / $2,104.98 / $2,168.13
| Professional | | $2,104.98 | $2,104.98 | $2,168.13 |