- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,461.77 / $2,461.77 / $2,461.77
| Facility | | $2,461.77 | $2,461.77 | $2,461.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,150.81 / $2,150.81 / $2,461.77
| Professional | | $2,150.81 | $2,150.81 | $2,461.77 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $978.50 / $2,202.64 / $2,202.64
| Facility | | $978.50 | $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 / $2,159.44
| Professional | | $2,159.44 | $2,159.44 | $2,159.44 |