- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,780.83 / $1,780.83 / $2,782.54
| Facility | | $1,780.83 | $1,780.83 | $2,782.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,780.83 / $2,776.24 / $3,206.09
| Professional | | $1,780.83 | $2,776.24 | $3,206.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,462.50 / $2,462.50 / $2,462.50
| Facility | | $2,462.50 | $2,462.50 | $2,462.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,462.50 / $2,462.50 / $2,462.50
| Professional | | $2,462.50 | $2,462.50 | $2,462.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,476.09 / $2,476.09 / $2,476.09
| Facility | | $2,476.09 | $2,476.09 | $2,476.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.55 / $1,807.55 / $2,476.09
| Professional | | $1,807.55 | $1,807.55 | $2,476.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.89 / $1,585.34 / $2,442.96
| Professional | | $1,056.89 | $1,585.34 | $2,442.96 |