- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,591.34 / $2,591.34 / $3,627.88
| Facility | | $2,591.34 | $2,591.34 | $3,627.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,591.34 / $2,591.34 / $2,591.34
| Professional | | $2,591.34 | $2,591.34 | $2,591.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $555.09 / $907.52 / $2,021.25
| Facility | | $555.09 | $907.52 | $2,021.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,021.25 / $2,021.25 / $2,061.67
| Professional | | $2,021.25 | $2,021.25 | $2,061.67 |
- 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
- $2,116.26 / $2,159.44 / $3,378.79
| Professional | | $2,116.26 | $2,159.44 | $3,378.79 |