- 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
- $2,600.06 / $2,600.06 / $3,900.09
| Facility | | $2,600.06 | $2,600.06 | $3,900.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,600.06 / $2,600.06 / $2,652.06
| Professional | | $2,600.06 | $2,600.06 | $2,652.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,554.44 / $2,554.44 / $2,554.44
| Facility | | $2,554.44 | $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
- Professional
- Modifier
- Low / Median / High Price
- $2,232.10 / $2,654.57 / $2,819.02
| Professional | | $2,232.10 | $2,654.57 | $2,819.02 |