- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.21 / $1,584.21 / $2,475.33
| Facility | | $1,584.21 | $1,584.21 | $2,475.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.21 / $2,376.32 / $2,748.28
| Professional | | $1,584.21 | $2,376.32 | $2,748.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,190.61 / $2,190.61 / $2,190.61
| Facility | | $2,190.61 | $2,190.61 | $2,190.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,190.61 / $2,190.61 / $2,190.61
| Professional | | $2,190.61 | $2,190.61 | $2,190.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,283.76 / $2,283.76
| Facility | | $2,283.76 | $2,283.76 | $2,283.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.14 / $1,667.14 / $2,283.76
| Professional | | $1,667.14 | $1,667.14 | $2,283.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.20 / $1,410.31 / $2,230.71
| Professional | | $891.20 | $1,410.31 | $2,230.71 |