- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.72 / $5,248.39 / $7,072.29
| Facility | | $1,828.72 | $5,248.39 | $7,072.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $1,828.72
| Professional | | $1,828.72 | $1,828.72 | $1,828.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.71 / $2,948.43 / $4,985.53
| Professional | | $1,828.71 | $2,948.43 | $4,985.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.20 / $1,725.20 / $1,828.71
| Facility | | $1,725.20 | $1,725.20 | $1,828.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.41 / $1,554.41 / $1,828.72
| Professional | | $1,554.41 | $1,554.41 | $1,828.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.14 / $1,828.72 / $2,963.95
| Professional | | $1,664.14 | $1,828.72 | $2,963.95 |