- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Facility | | $2,147.08 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,071.30 / $2,147.08 / $2,147.08
| Professional | | $2,071.30 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Facility | | $2,147.08 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Professional | | $2,147.08 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.98 / $2,104.98 / $2,525.98
| Professional | | $2,104.98 | $2,104.98 | $2,525.98 |