- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.13 / $1,861.13 / $1,861.13
| Facility | | $1,861.13 | $1,861.13 | $1,861.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $1,861.13
| Professional | | $1,828.72 | $1,828.72 | $1,861.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,261.96 / $3,837.60 / $3,837.60
| Professional | | $3,261.96 | $3,837.60 | $3,837.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.20 / $1,725.20 / $1,725.20
| Facility | | $1,725.20 | $1,725.20 | $1,725.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.71 / $1,828.71 / $2,587.80
| Professional | | $1,828.71 | $1,828.71 | $2,587.80 |
- 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 |