- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,113.23 / $2,113.23 / $2,113.23
| Facility | | $2,113.23 | $2,113.23 | $2,113.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.23 / $2,113.23 / $2,116.32
| Professional | | $2,113.23 | $2,113.23 | $2,116.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.57 / $2,426.55 / $2,426.55
| Professional | | $2,062.57 | $2,426.55 | $2,426.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,996.53 / $1,996.53 / $1,996.53
| Facility | | $1,996.53 | $1,996.53 | $1,996.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,994.80
| Professional | | $2,116.32 | $2,116.32 | $2,994.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,116.32
| Professional | | $2,116.32 | $2,116.32 | $2,116.32 |