- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,996.07 / $2,996.07 / $2,996.07
| Facility | | $2,996.07 | $2,996.07 | $2,996.07 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $747.68 / $938.53 / $2,448.50
| Facility | | $747.68 | $938.53 | $2,448.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.98 / $2,147.08 / $2,147.08
| Professional | | $2,104.98 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Facility | | $2,147.08 | $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
- $2,147.08 / $2,147.08 / $2,572.42
| Professional | | $2,147.08 | $2,147.08 | $2,572.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,996.07 / $2,996.07 / $2,996.07
| Facility | | $2,996.07 | $2,996.07 | $2,996.07 |
- 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
- $1,609.31 / $2,104.98 / $3,052.22
| Professional | | $1,609.31 | $2,104.98 | $3,052.22 |