- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,038.50 / $2,038.50 / $2,038.50
| Facility | | $2,038.50 | $2,038.50 | $2,038.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $2,073.86 / $2,092.88
| Professional | | $1,902.62 | $2,073.86 | $2,092.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,295.00 / $2,700.00 / $2,700.00
| Professional | | $2,295.00 | $2,700.00 | $2,700.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.93 / $1,794.93 / $1,794.93
| Facility | | $1,794.93 | $1,794.93 | $1,794.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $2,692.39 / $2,692.39
| Professional | | $1,902.62 | $2,692.39 | $2,692.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Professional | | $1,902.62 | $1,902.62 | $1,902.62 |