- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,151.21 / $2,151.21 / $2,151.21
| Facility | | $2,151.21 | $2,151.21 | $2,151.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,151.21
| Professional | | $2,068.46 | $2,068.46 | $2,151.21 |
- 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 / $2,068.46
| Professional | | $2,068.46 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,068.46
| Professional | | $2,068.46 | $2,068.46 | $2,068.46 |