- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,202.64 / $2,202.64 / $2,202.64
| Facility | | $2,202.64 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,150.81 / $2,150.81 / $2,202.64
| Professional | | $2,150.81 | $2,150.81 | $2,202.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,159.44 / $2,159.44 / $2,159.44
| Facility | | $2,159.44 | $2,159.44 | $2,159.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.44 / $2,159.44 / $2,159.44
| Professional | | $2,159.44 | $2,159.44 | $2,159.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,837.41 / $2,202.64 / $2,202.64
| Facility | | $1,837.41 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,202.64 / $2,202.64 / $2,202.64
| Professional | | $2,202.64 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.44 / $2,159.44 / $2,871.97
| Professional | | $2,159.44 | $2,159.44 | $2,871.97 |