- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,220.57 / $2,220.57 / $2,220.57
| Facility | | $2,220.57 | $2,220.57 | $2,220.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,254.63 / $2,275.32
| Professional | | $2,068.46 | $2,254.63 | $2,275.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,825.40 / $3,324.00 / $3,324.00
| Professional | | $2,825.40 | $3,324.00 | $3,324.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,951.39 / $1,951.39 / $1,951.39
| Facility | | $1,951.39 | $1,951.39 | $1,951.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,927.08 / $2,927.08
| Professional | | $2,068.46 | $2,927.08 | $2,927.08 |
- 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 |