- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,127.48 / $2,127.48 / $2,127.48
| Facility | | $2,127.48 | $2,127.48 | $2,127.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.89 / $2,127.48 / $2,127.48
| Professional | | $1,969.89 | $2,127.48 | $2,127.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,858.38 / $1,858.38 / $1,969.89
| Facility | | $1,858.38 | $1,858.38 | $1,969.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.89 / $1,969.89 / $1,969.89
| Professional | | $1,969.89 | $1,969.89 | $1,969.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,879.03 / $2,029.35 / $3,131.71
| Facility | | $1,879.03 | $2,029.35 | $3,131.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,789.55 / $1,789.55 / $9,454.20
| Professional | | $1,789.55 | $1,789.55 | $9,454.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.89 / $1,969.89 / $2,182.64
| Professional | | $1,969.89 | $1,969.89 | $2,182.64 |