- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,741.23 / $1,741.23 / $2,720.67
| Facility | | $1,741.23 | $1,741.23 | $2,720.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.23 / $2,560.78 / $3,210.88
| Professional | | $1,741.23 | $2,560.78 | $3,210.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,407.75 / $2,407.75 / $2,407.75
| Facility | | $2,407.75 | $2,407.75 | $2,407.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.75 / $2,407.75 / $2,407.75
| Professional | | $2,407.75 | $2,407.75 | $2,407.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,479.82 / $2,479.82 / $2,479.82
| Facility | | $2,479.82 | $2,479.82 | $2,479.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.27 / $1,810.27 / $2,479.82
| Professional | | $1,810.27 | $1,810.27 | $2,479.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.39 / $1,550.09 / $2,388.64
| Professional | | $1,033.39 | $1,550.09 | $2,388.64 |