- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Facility | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Professional | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,364.89 / $2,554.44 / $2,554.44
| Facility | | $2,364.89 | $2,554.44 | $2,554.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.44 / $2,554.44 / $2,554.44
| Professional | | $2,554.44 | $2,554.44 | $2,554.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Facility | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Professional | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.17 / $2,349.17 / $2,772.03
| Professional | | $2,349.17 | $2,349.17 | $2,772.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.41 / $2,182.57 / $2,182.57
| Professional | | $110.41 | $2,182.57 | $2,182.57 |