- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,482.17 / $2,482.17 / $2,482.17
| Facility | | $2,482.17 | $2,482.17 | $2,482.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,171.90 / $2,482.17
| Professional | | $2,068.46 | $2,171.90 | $2,482.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,409.11 / $2,409.11 / $2,409.11
| Facility | | $2,409.11 | $2,409.11 | $2,409.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.70 / $2,409.11 / $2,409.11
| Professional | | $182.70 | $2,409.11 | $2,409.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,951.39 / $2,068.46 / $2,068.46
| Facility | | $1,951.39 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,244.10
| Professional | | $2,068.46 | $2,068.46 | $2,244.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,965.05 / $2,068.46 / $2,358.06
| Professional | | $1,965.05 | $2,068.46 | $2,358.06 |