- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.72 / $2,419.46 / $3,954.90
| Facility | | $1,828.72 | $2,419.46 | $3,954.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $2,251.96
| Professional | | $1,828.72 | $1,828.72 | $2,251.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,837.60 / $3,837.60 / $3,837.60
| Professional | | $3,837.60 | $3,837.60 | $3,837.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.71 / $1,828.71 / $1,828.71
| Facility | | $1,828.71 | $1,828.71 | $1,828.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.71 / $1,828.71 / $1,828.71
| Professional | | $1,828.71 | $1,828.71 | $1,828.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,565.20 / $15,218.75 / $15,218.75
| Facility | | $3,565.20 | $15,218.75 | $15,218.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $3,261.96
| Professional | | $1,828.72 | $1,828.72 | $3,261.96 |