- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,855.26 / $1,855.26 / $2,898.85
| Facility | | $1,855.26 | $1,855.26 | $2,898.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,855.26 / $2,898.85 / $3,438.72
| Professional | | $1,855.26 | $2,898.85 | $3,438.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,565.44 / $2,565.44 / $2,565.44
| Facility | | $2,565.44 | $2,565.44 | $2,565.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,565.44 / $2,565.44 / $2,565.44
| Professional | | $2,565.44 | $2,565.44 | $2,565.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,482.86 / $2,482.86 / $2,482.86
| Facility | | $2,482.86 | $2,482.86 | $2,482.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.49 / $1,812.49 / $2,482.86
| Professional | | $1,812.49 | $1,812.49 | $2,482.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,182.50 / $2,182.50 / $2,545.08
| Facility | | $2,182.50 | $2,182.50 | $2,545.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.07 / $1,651.61 / $2,545.08
| Professional | | $1,101.07 | $1,651.61 | $2,545.08 |