- 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 / $2,819.38
| Professional | | $2,202.64 | $2,202.64 | $2,819.38 |
- 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
- 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
- $607.08 / $874.19 / $3,040.91
| Professional | | $607.08 | $874.19 | $3,040.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.44 / $2,159.44 / $3,378.79
| Professional | | $2,159.44 | $2,159.44 | $3,378.79 |