- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $3,090.30
| Facility | | $2,137.96 | $2,137.96 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,137.96 / $3,090.30
| Professional | | $2,089.30 | $2,137.96 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Professional | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,344.23 / $2,344.23
| Facility | | $2,187.76 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,290.87 / $3,467.37
| Professional | | $2,089.30 | $2,290.87 | $3,467.37 |