- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,979.77 / $1,979.77 / $3,155.26
| Facility | | $1,979.77 | $1,979.77 | $3,155.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,979.77 / $2,392.54 / $3,155.26
| Professional | | $1,979.77 | $2,392.54 | $3,155.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,737.60 / $2,737.60 / $2,737.60
| Facility | | $2,737.60 | $2,737.60 | $2,737.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,737.60 / $2,737.60 / $2,737.60
| Professional | | $2,737.60 | $2,737.60 | $2,737.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,507.59 / $2,507.59 / $2,507.59
| Facility | | $2,507.59 | $2,507.59 | $2,507.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.54 / $1,830.54 / $2,507.59
| Professional | | $1,830.54 | $1,830.54 | $2,507.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.96 / $1,677.14 / $2,715.88
| Professional | | $1,174.96 | $1,677.14 | $2,715.88 |