- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,914.55 / $3,206.00 / $3,206.00
| Facility | | $2,914.55 | $3,206.00 | $3,206.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.55 / $2,914.55 / $3,130.56
| Professional | | $2,914.55 | $2,914.55 | $3,130.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,914.55 / $2,914.55 / $2,914.55
| Facility | | $2,914.55 | $2,914.55 | $2,914.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.55 / $2,914.55 / $4,354.68
| Professional | | $2,914.55 | $2,914.55 | $4,354.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,233.76 / $4,233.76 / $4,233.76
| Facility | | $4,233.76 | $4,233.76 | $4,233.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,771.68 / $2,857.40 / $4,138.37
| Professional | | $2,771.68 | $2,857.40 | $4,138.37 |