- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,772.06 / $2,899.64
| Facility | | $1,772.06 | $1,772.06 | $2,899.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.06 / $2,899.64 / $2,899.64
| Professional | | $1,772.06 | $2,899.64 | $2,899.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,603.89 / $2,406.83 / $3,415.34
| Facility | | $1,603.89 | $2,406.83 | $3,415.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.06 / $2,358.66 / $2,899.64
| Professional | | $1,772.06 | $2,358.66 | $2,899.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.53 / $821.45 / $1,095.27
| Facility | | $109.53 | $821.45 | $1,095.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.64 / $1,216.33 / $2,027.22
| Professional | | $1,088.64 | $1,216.33 | $2,027.22 |