- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $2,820.47
| Facility | | $1,786.79 | $1,786.79 | $2,820.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.79 / $2,273.92 / $2,820.47
| Professional | | $1,786.79 | $2,273.92 | $2,820.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $865.13 / $1,786.79 / $3,229.84
| Facility | | $865.13 | $1,786.79 | $3,229.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.79 / $2,273.92 / $2,820.47
| Professional | | $1,786.79 | $2,273.92 | $2,820.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.19 / $1,340.09 / $2,233.48
| Professional | | $1,211.19 | $1,340.09 | $2,233.48 |