- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,625.24
| Facility | | $3,081.45 | $3,081.45 | $3,625.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,008.95 / $3,081.45 / $3,081.45
| Professional | | $3,008.95 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $947.73 / $978.60 / $1,712.55
| Facility | | $947.73 | $978.60 | $1,712.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Facility | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $4,604.05
| Professional | | $3,081.45 | $3,081.45 | $4,604.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,963.68 / $3,021.04 / $3,625.24
| Professional | | $1,963.68 | $3,021.04 | $3,625.24 |