- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,574.65 / $2,574.65 / $5,471.13
| Facility | | $2,574.65 | $2,574.65 | $5,471.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.65 / $2,574.65 / $2,574.65
| Professional | | $2,574.65 | $2,574.65 | $2,574.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.85 / $1,029.85 / $1,673.52
| Professional | | $1,029.85 | $1,029.85 | $1,673.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.65 / $2,574.65 / $2,600.40
| Professional | | $2,574.65 | $2,574.65 | $2,600.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,574.65 / $2,574.65 / $4,170.93
| Facility | | $2,574.65 | $2,574.65 | $4,170.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.65 / $2,574.65 / $2,574.65
| Professional | | $2,574.65 | $2,574.65 | $2,574.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.79 / $1,544.79 / $3,861.98
| Professional | | $1,544.79 | $1,544.79 | $3,861.98 |