- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Facility | | $2,784.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $3,062.82
| Professional | | $2,784.38 | $2,784.38 | $3,062.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Facility | | $2,784.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.35 / $2,784.38 / $2,784.38
| Professional | | $633.35 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,422.41 / $2,784.38 / $2,784.38
| Professional | | $2,422.41 | $2,784.38 | $2,784.38 |