- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,198.35 / $2,198.35 / $4,671.49
| Facility | | $2,198.35 | $2,198.35 | $4,671.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,198.35 / $2,198.35 / $2,198.35
| Professional | | $2,198.35 | $2,198.35 | $2,198.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.34 / $879.34 / $1,428.92
| Professional | | $879.34 | $879.34 | $1,428.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,198.35 / $2,198.35 / $2,220.33
| Professional | | $2,198.35 | $2,198.35 | $2,220.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,198.35 / $2,198.35 / $3,561.33
| Facility | | $2,198.35 | $2,198.35 | $3,561.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,198.35 / $2,198.35 / $2,198.35
| Professional | | $2,198.35 | $2,198.35 | $2,198.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.01 / $1,319.01 / $3,297.53
| Professional | | $1,319.01 | $1,319.01 | $3,297.53 |