- 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
- $2,202.64 / $2,202.64 / $2,202.64
| Professional | | $2,202.64 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,073.07 / $2,073.07 / $2,073.07
| Professional | | $2,073.07 | $2,073.07 | $2,073.07 |
- 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
- $1,381.28 / $1,381.28 / $1,381.28
| Professional | | $1,381.28 | $1,381.28 | $1,381.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,965.10 / $2,159.44 / $3,499.99
| Professional | | $1,965.10 | $2,159.44 | $3,499.99 |