- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,976.55 / $1,976.55 / $1,976.55
| Facility | | $1,976.55 | $1,976.55 | $1,976.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,976.55 / $1,976.55 / $2,016.42
| Professional | | $1,976.55 | $1,976.55 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.69 / $2,540.81 / $2,540.81
| Professional | | $2,159.69 | $2,540.81 | $2,540.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.29 / $1,902.29 / $1,902.29
| Facility | | $1,902.29 | $1,902.29 | $1,902.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,853.43
| Professional | | $2,016.42 | $2,016.42 | $2,853.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |